Left ventricular hypertrophy in athletes

Systematic echocardiography is not efficacious when screening an ethnically diverse cohort of athletes in West Asia

BACKGROUND

The clinical and economic value of including systematic echocardiography (ECHO) alongside the 12-lead electrocardiograpm (ECG) when undertaking pre-participation screening in athletes has not been examined, yet several sporting organistations recommend its inclusion.

DESIGN

To examine the efficacy of systematic ECHO alongside the ECG, to identify sudden cardiac death (SCD) disease and to provide a cost-analysis of a government-funded pre-participation screening programme.

METHODS

A total 1628 athletes presented for cardiological consultation, ECG, and ECHO as standard, with further cardiac examinations performed if necessary to confirm or exclude pathology. The efficacy of systematic ECHO was compared to an ECG-led programme, with ECHO reserved as a follow-up examination.

RESULTS

To screen 1628 athletes with ECG and ECHO cost US$743,996. There were 54 24-h-blood pressure/ECG Holter recordings, 62 exercise tests, 25 CMRs, two electrophysiological studies, and two genetic tests, which cost US$67,734: total US$811,730. Eight athletes (0.5%) were identified with hypertrophic cardiomyopathy (HCM) and two (0.1%) with Wolff-Parkinson-White syndrome. The cost per identifed athlete was US$81,173. All 10 athletes presented an abnormal ECG. No athlete diagnosed with HCM was identified by ECHO in isolation. When adopting a ECG-led screening protocol, 15% of athletes required ECHO as a follow-up examination, resulting in a US$380,600 cost reduction (47% saving), with the cost per diagnosis reduced to US$43,113.

CONCLUSIONS

Athletes diagnosed with a disease associated with SCD were identified via an abnormal ECG and/or physical examination, personal symptoms, or family history. Screening athletes with systematic ECHO is not economically or clinically effective.

The effect of aerobic continuous and interval training on left ventricular structure and function in male non-athletes

Exercise plays an important role to improve cardiovascular performance. The aim of this study was to compare the effect of aerobic continuous and interval training on the left ventricular structure and function. Twenty untrained healthy male students (aged 18-22 years) were randomly divided into two groups: continuous (C; n = 10) and interval (I; n = 10). The training programme consisted of countryside jogging for 45 min during 8 weeks three times a week at 70% of maximum heart rate (MHR). In each session group C was jogging for 45 min and in group I jogging was performed in 5 nine-minute stages with a four-minute inactive rest between them. M-mode, 2-dimensional, colour and Doppler transthoracic echocardiography were performed, during resting conditions, before and after the training period. After 8-week training the end diastolic diameter, systolic blood pressure and diastolic blood pressure in groups C and I, and the posterior wall thickness and the end systolic diameter in group I showed no significant difference (P > 0.05). On the other hand, the percentage of ejection fraction and shortening fraction in groups C and I, the end systolic diameter and the posterior wall thickness in group C and the interventricular septum thickness in group I demonstrated a significant difference (P ≤ 0.05). Comparing the two groups, only the value of the interventricular septum thickness was significant (P ≤ 0.05). In general, eight-week aerobic continuous and interval training can affect left ventricular structure and function.

Arrhythmias in athletes: evidence-based strategies and challenges for diagnosis, management, and sports eligibility

Assessment and management of cardiac rhythm disorders in athletes is particularly challenging. An accurate diagnosis and optimal risk-stratification are often limited because of substantial phenotypic overlap between pathological entities and adaptive cardiovascular responses that normally occur in athletes. An accurate diagnosis, however, is particularly important in this population, as 2 competing risks need to be cautiously balanced: the risk of under-diagnosis of an arrhythmogenic substrate that may trigger life-threatening events versus the risk of over-diagnosis that may result in an athlete's improper disqualification. Accordingly, the management of arrhythmias in athletes may pose therapeutic dilemmas, and often differs substantially compared with the general population. In this review, we present the most frequently observed arrhythmias in athletes and briefly discuss their pathophysiologic substrate. We further propose diagnostic and therapeutic strategies based upon current guidelines, official recommendations, and emerging evidence from relevant clinical investigations. We focus particularly on disparities in current guidelines regarding the management of certain rhythm disorders, as these areas of uncertainty may reflect the challenging nature of these disorders and may indicate the need for individualized approaches in every-day clinical practice. A better understanding of the normal electrophysiological responses to chronic exercise, and of the pathophysiological basis and the true clinical significance of arrhythmias in athletes, may enhance decision-making, and may allow for management strategies which more prudently weigh the risk-to-benefit ratio of each approach.

Significance of false negative electrocardiograms in preparticipation screening of athletes for hypertrophic cardiomyopathy

Preparticipation screening of athletes with 12-lead electrocardiography has been promoted for the detection of asymptomatic cardiovascular disease, particularly hypertrophic cardiomyopathy (HC). Although false-positive electrocardiographic (ECG) results for HC are well recognized in athlete screening, expected false-negative rates are unknown. The aim of this study was to characterize the rate of false-negative ECG findings in a cohort of young asymptomatic patients with phenotypically expressed HC, defined by cardiovascular magnetic resonance, using the 2010 European Society of Cardiology recommended ECG criteria for the identification of suspected heart disease in trained athletes. Cardiac magnetic resonance studies and 12-lead electrocardiography were performed in 114 consecutive asymptomatic patients with HC aged ≤35 years (mean age 22 ± 8 years; 77% male patients). Electrocardiograms were analyzed to distinguish pathologic ECG patterns from alterations considered nonpathologic and physiologic consequences of athletic training. Among the 114 patients with HC, 103 (90%) demonstrated ≥1 pathologic ECG abnormality, while the remaining 11 patients (10%) had normal or nonpathologic ECG patterns and therefore defined a subgroup in whom ECG screening would not be expected to raise suspicion of heart disease (i.e., false-negative results). In this false-negative ECG results group, maximal left ventricular wall thickness was 17 ± 2 mm (range 15 to 21), compared to patients with pathologic ECG patterns, in whom maximal left ventricular wall thickness was 22 ± 5 mm (p = 0.003). In conclusion, a substantial minority of young asymptomatic patients with HC with phenotypically expressed left ventricular hypertrophy have nonpathologic ECG findings on the basis of the 2010 European Society of Cardiology guidelines. In principle, this high false-negative rate of 10% represents an important limitation in applying 12-lead electrocardiography to large, apparently healthy athletic populations for the detection of HC.

[Athlete's heart or hypertrophic cardiomyopathy?]

High level of physical training can lead cardiovascular quantitative and qualitative adaptations. These clinical, electrical and echocardiographic adaptations are called athlete's heart. These mainly moderated adaptations raise generally no diagnostic issue. However, in rare cases, the question of the limits of athlete's heart may arise. The differential diagnosis with the hypertrophic cardiomyopathy is important because this pathology, even treated, excludes for intense physical activity. On the contrary, an inequitable contraindication for competitive sport is not acceptable. In most cases, the athlete's heart diagnosis is easy in case of a good knowledge of its signs and a good rigor of exam. However, sometimes, the good diagnosis is proposed only on a beam of arguments.

Left ventricle fibrosis associated with nonsustained ventricular tachycardia in an elite athlete: is exercise responsible? A case report

OBJECTIVE

To emphasize the potentially harmful effects of high-intensity exercise on cardiac health and the fine line between physiologic and pathologic adaptation to chronic exercise in the elite athlete. This case also highlights the crucial need for regular evaluation of symptoms that suggest cardiac abnormality in athletes.

BACKGROUND

Sudden cardiac death (SCD) of young athletes is always a tragedy because they epitomize health. However, chronic, high-intensity exercise sometimes has harmful effects on cardiac health, and pathologic changes, such as myocardial fibrosis, have been observed in endurance athletes. In this case, a highly trained 30-year-old cyclist reported brief palpitations followed by presyncope feeling while exercising. Immediate investigations revealed nonsustained ventricular tachycardia originating from the left ventricle on a stress test associated with myocardial fibrosis of the left ventricle as shown with magnetic resonance imaging. Despite complete cessation of exercise, life-threatening arrhythmia and fibrosis persisted, leading to complete restriction from competition. Differential Diagnosis: Hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, myocarditis, postmyocarditis, use of drugs and toxic agents, doping, and systemic disease.

TREATMENT

The arrhythmia could not be treated with catheter ablation procedure or drug suppression. Therefore, the athlete was instructed to withdraw completely from sport participation and to have a medical follow-up twice each year.

UNIQUENESS

To our knowledge, no other report of left ventricle exercise-induced fibrosis associated with life-threatening arrhythmia in a living young elite athlete exists. Only postmortem evidence supports such myocardial pathologic adaptation to exercise.

CONCLUSIONS

To prevent SCD in young athletes, careful attention must be paid to exercise-related symptoms that suggest a cardiac abnormality because they more often are linked to life-threatening cardiovascular disease.

Noninvasive imaging modalities and sudden cardiac arrest in the young: can they help distinguish subjects with a potentially life-threatening abnormality from normals?

Sudden cardiac arrest (SCA) in the young is always tragic, but fortunately it is an unusual event. When it does occur, it usually happens in active individuals, often while they are participating in physical activity. Depending on the population's characteristics, the most common causes of sudden cardiac arrest in these subjects are hypertrophic cardiomyopathy, congenital coronary abnormalities, arrhythmia in the presence of a structurally normal heart (ion channelopathies or abnormal conduction pathways), aortic rupture, and arrhythmogenic right-ventricular cardiomyopathy. Two-dimensional echocardiography (2-DE) has been proposed as a screening tool that can potentially detect four of these five causes of SCA, and many groups now sponsor community-based 2-DE SCA-screening programs. "Basic" 2-DE screening may include assessment of ventricular volumes, mass, and function; left atrial size; and cardiac and thoracic vascular (including coronary) anatomy. "Advanced" echocardiographic techniques, such as tissue Doppler and strain imaging, can help in diagnosis when the history, electrocardiogram (ECG), and/or standard 2-DE screening suggest there may be an abnormality, e.g., to help differentiate those with "athlete's heart" from hypertrophic or dilated cardiomyopathy. Cardiac magnetic resonance imaging or cardiac computed tomography can be added to increase diagnostic sensitivity and specificity in select cases when an abnormality is suggested during SCA screening. Test availability, cost, and ethical issues related to who to screen, as well as the detection of those with potential disease but low risk, must be balanced when deciding what tests to perform to assess for increased SCA risk.

Hypertension in special populations: athletes

Physical exercise is known to lower blood pressure and reduce cardiovascular risk through a wide range of mechanisms. Nevertheless, hypertension is the most prevalent cardiovascular disease among athletes and physically active subjects. This article reviews the state of the art in practical approaches to this issue, focusing on special aspects a physician should take into account when diagnosing hypertension, such as screening of secondary causes, assessment of global cardiovascular risk and target organ damage and, in addition, the treatment choice in athletes.

Influences of the G2350A polymorphism in the ACE gene on cardiac structure and function of ball game players

Background

Except for the I/D polymorphism in the angiotensin I-converting enzyme (ACE) gene, there were few reports about the relationship between other genetic polymorphisms in this gene and the changes in cardiac structure and function of athletes. Thus, we investigated whether the G2350A polymorphism in the ACE gene is associated with the changes in cardiac structure and function of ball game players. Total 85 healthy ball game players were recruited in this study, and they were composed of 35 controls and 50 ball game players, respectively. Cardiac structure and function were measured by 2-D echocardiography, and the G2350A polymorphism in the ACE gene analyzed by the SNaPshot method.

Results

There were significant differences in left ventricular mass index (LVmassI) value among each sporting discipline studied. Especially in the athletes of basketball disciplines, indicated the highest LVmassI value than those of other sporting disciplines studied (p < 0.05). However, there were no significant association between any echocardiographic data and the G2350A polymorphism in the ACE gene in the both controls and ball game players.

Conclusions

Our data suggests that the G2350A polymorphism in the ACE gene may not significantly contribute to the changes in cardiac structure and function of ball game players, although sporting disciplines of ball game players may influence the changes in LVmassI value of these athletes. Further studies using a larger sample size and other genetic markers in the ACE gene will be needed.

Hypertrophic cardiomyopathy and ultra-endurance running - two incompatible entities?

Regular and prolonged exercise is associated with increased left ventricular wall thickness that can overlap with hypertrophic cardiomyopathy (HCM). Differentiating physiological from pathological hypertrophy has important implications, since HCM is the commonest cause of exercise-related sudden cardiac death in young individuals. Most deaths have been reported in intermittent 'start-stop' sports such as football (soccer) and basketball. The theory is that individuals with HCM are unable to augment stroke volume sufficiently to meet the demands of endurance sports and are accordingly 'selected-out' of participation in such events. We report the case of an ultra-endurance athlete with 25 years of > 50 km competitive running experience, with genetically confirmed HCM; thereby demonstrating that these can be two compatible entities.

The effect of exercise training on left ventricular function in young elite athletes

BACKGROUND

Regular training, in particular endurance exercise, induces structural myocardial adaptation, so-called "athlete's heart". In addition to the 2D standard echo parameters, assessment of myocardial function is currently possible by deformation parameters (strain, rotation and twist). Aim of study is to assess the role of rotation and twist parameters for better characterize the heart performance in trained elite young athletes from different kind of sports. Eventually, verify early on any possible impact due to the regular sport activity not revealed by the standard parameters.

METHODS

50 young athletes (16 cyclists, 17 soccer players, 17 basket players) regularly trained at least three times a week for at least 9 months a year and 10 young controls (mean age 18.5 ± 0.5 years) were evaluated either by to 2D echocardiography or by a Speckle Tracking (ST) multi-layer approach to calculate Left Ventricle (LV) endocardial and epicardial rotation, twist, circumferential strain (CS) and longitudinal strain (LS). Data were compared by ANOVA test.

RESULTS

All the found values were within the normal range. Left Ventricle Diastolic Diameter (LVDD 51.7 ± 2.6 mm), Cardiac Mass index (CMi 114.5 ± 18.5 g/m²), epi-CS, epi-LS, epicardial apex rotation and the Endo/Epi twist were significantly higher only in cyclists. In all the groups, a physiological difference of the Endo/Epi basal circumferential strain and twist values have been found. A weak but not significant relationship between the Endo and twist values and LVDD (r² = 0.44, p = .005) and CMi was also reported in cyclists.

CONCLUSIONS

Progressive increase of apical LV twist may represent an important component of myocardial remodelling. This aspect is particularly evident in the young cyclists group where the CMi and the LVDD are higher. ST multilayer approach completes the LV performance evaluation in young trained athletes showing values similar to adults.