Echocardiographic Characterization of Female Professional Basketball Players in the US

Racial Disparities in Sports Cardiology: A Review

Importance

Racial disparities in cardiovascular health, including sudden cardiac death (SCD), exist among both the general and athlete populations. Among competitive athletes, disparities in health outcomes potentially influenced by social determinants of health (SDOH) and structural racism remain inadequately understood. This narrative review centers on race in sports cardiology, addressing racial disparities in SCD risk, false-positive cardiac screening rates among athletes, and the prevalence of left ventricular hypertrophy, and encourages a reexamination of race-based practices in sports cardiology, such as the interpretation of screening 12-lead electrocardiogram findings.

Observations

Drawing from an array of sources, including epidemiological data and broader medical literature, this narrative review discusses racial disparities in sports cardiology and calls for a paradigm shift in approach that encompasses 3 key principles: race-conscious awareness, clinical inclusivity, and research-driven refinement of clinical practice. These proposed principles call for a shift away from race-based assumptions towards individualized, health-focused care in sports cardiology. This shift would include fostering awareness of sociopolitical constructs, diversifying the medical team workforce, and conducting diverse, evidence-based research to better understand disparities and address inequities in sports cardiology care.

Conclusions and Relevance

In sports cardiology, inadequate consideration of the impact of structural racism and SDOH on racial disparities in health outcomes among athletes has resulted in potential biases in current normative standards and in the clinical approach to the cardiovascular care of athletes. An evidence-based approach to successfully address disparities requires pivoting from outdated race-based practices to a race-conscious framework to better understand and improve health care outcomes for diverse athletic populations.

Electrocardiographic Findings in Female Professional Basketball Athletes

Importance

Previous studies of professional basketball athletes have characterized manifestations of athletic remodeling by echocardiography and electrocardiography (ECG) in males and echocardiography in females. There is a paucity of female, basketball-specific ECG data.

Objective

To generate reference range ECG data for female professional basketball athletes.

Design, Setting, and Participants

This is a cross-sectional study of ECGs performed on female professional basketball athletes. The Women's National Basketball Association mandates annual preseason ECGs and echocardiograms for each athlete and has partnered with Columbia University Irving Medical Center to annually review these studies. Data for this study were collected during preseason ECG and echocardiography cardiac screening between April and May 2022. Data analysis was performed between February and July 2023.

Exposure

Athlete ECGs and echocardiograms were sent to Columbia University Irving Medical Center for core lab analysis.

Main Outcomes and Measures

Quantitative ECG variables were measured. ECG data were qualitatively analyzed for training-related and abnormal findings using the International Recommendations for Electrocardiographic Interpretation in Athletes. Findings from ECGs were compared with corresponding echocardiographic data.

Results

There were a total of 173 athletes (mean [SD] age 26.5 [4.1] years; mean [SD] height, 183.4 [9.1] cm; mean [SD] body surface area, 2.0 [0.2] m2), including 129 Black athletes (74.5%) and 40 White athletes (23.1%). By international criteria, 136 athletes (78.6%) had training-related ECG changes and 8 athletes (4.6%) had abnormal ECG findings. Among athletes with at least 1 training-related ECG finding, left ventricular structural adaptations associated with athletic remodeling were present in 64 athletes (47.1%). Increased relative wall thickness, reflecting concentric left ventricular geometry, was more prevalent in athletes with the repolarization variant demonstrating convex ST elevation combined with T-wave inversions in leads V1 to V4 (6 of 12 athletes [50.0%]) than in athletes with early repolarization (5 of 42 athletes [11.9%]) (odds ratio, 7.40; 95% CI, 1.71-32.09; P = .01). Abnormal ECG findings included T-wave inversions (3 athletes [1.7%]), Q waves (2 athletes [1.2%]), prolonged QTc interval (2 athletes [1.2%]), and frequent premature ventricular contractions (1 athlete [0.6%]).

Conclusions and Relevance

This cross-sectional study provides reference ECG data for elite female basketball athletes. International criteria-defined training-related findings were common, whereas abnormal ECG findings were rare in this athlete group. These reference data may assist basketball programs and health care professionals using ECGs in screening for female athletes and may be used as a stimulus for future female-specific ECG inquiries.

Asian Female Athlete's Heart: The CHIEF Heart Study

Background

The cardiac characteristics of Asian female endurance athletes and strength athletes have rarely been investigated.

Methods

This study included 177 Taiwanese young women undergoing military training. Cardiac features were assessed by electrocardiography (ECG) and echocardiography. Then, all participants completed a 3000-meter run to assess endurance capacity, and 89 participants completed a 2-minute push-up test to assess muscular strength. Athletes were those whose exercise performance fell one standard deviation above the mean, and the remaining participants were defined as controls. Multiple logistic regression analysis was used to determine the predictors of the cardiac characteristics of female athletes.

Results

Compared to the female controls, female endurance athletes had a greater QRS duration (ms) (92.12 ± 10.35 vs. 87.26 ± 9.89, p = 0.01) and a higher prevalence of right axis deviation (RAD) (34.9% vs. 11.1%, p < 0.001). There were no differences in any echocardiographic parameters. Greater QRS duration and RAD and lower systolic blood pressure were independent predictors of female endurance athletes [odds ratios (OR) and 95% confidence intervals: 1.05 (1.01-1.09), 2.91 (1.12-7.59) and 0.93 (0.88-0.98), respectively]. Female strength athletes had a greater right ventricular outflow tract (RVOT) (mm) (28.06 ± 3.57 vs. 25.38 ± 3.61, p = 0.007) but revealed no differences in ECG variables. Greater RVOT was the only predictor of female strength athletes [OR: 1.26 (1.05-1.50)].

Conclusions

In Asian military women, a wider QRS duration and the presence of RAD in ECG rather than heart structure and function were found to characterize endurance athletes, whereas a wider RVOT but no ECG features were found to characterize strength athletes.

Normal reference values for mitral annular plane systolic excursion by motion-mode and speckle tracking echocardiography: a prospective, multicentre, population-based study

AIMS

Mitral annular plane systolic excursion (MAPSE) is a simple and reliable index for evaluating left ventricular (LV) systolic function, particularly in patients with poor image quality; however, the lack of reference values limits its widespread use. This study aimed to establish the normal ranges for MAPSE measured using motion-mode (M-mode) and two-dimensional speckle tracking echocardiography (2D-STE) and to explore its principal determinants.

METHODS AND RESULTS

This multicentre, prospective, cross-sectional study included 1952 healthy participants [840 men (43%); age range, 18-80 years] from 55 centres. MAPSE was measured using M-mode echocardiography and 2D-STE. The results showed that women had a higher MAPSE than men and MAPSE decreased with age. The age- and sex-specific reference values for MAPSE were established for these two methods. Multiple linear regression analyses revealed that MAPSE on M-mode echocardiography correlated with age and MAPSE on 2D-STE with age, blood pressure (BP), heart rate, and LV volume. Moreover, MAPSE measured by 2D-STE correlated more strongly with global longitudinal strain compared with that measured using M-mode echocardiography.

CONCLUSION

Normal MAPSE reference values were established based on age and sex. BP, heart rate, and LV volume are potential factors that influence MAPSE and should be considered in clinical practice. Normal values are useful for evaluating LV longitudinal systolic function, especially in patients with poor image quality, and may further facilitate the use of MAPSE in routine assessments.

Impact of Sex on Cardiovascular Adaptations to Exercise: JACC Review Topic of the Week

Routine exercise leads to cardiovascular adaptations that differ based on sex. Use of cardiac testing to screen athletes has driven research to define how these sex-based adaptations manifest on the electrocardiogram and cardiac imaging. Importantly, sex-based differences in cardiovascular structure and outcomes in athletes often parallel findings in the general population, underscoring the importance of understanding their mechanisms. Substantial gaps exist in the understanding of why cardiovascular adaptations and outcomes related to exercise differ by sex because of underrepresentation of female participants in research. As female sports participation rates have increased dramatically over several decades, it also remains unknown if differences observed in older athletes reflect biological mechanisms vs less lifetime access to sports in females. In this review, we will assess the effect of sex on cardiovascular adaptations and outcomes related to exercise, identify the impact of sex hormones on exercise performance, and highlight key areas for future research.

The Relationships Between 25-Hydroxyvitamin D and Echocardiographic Parameters in Female Basketball Players

OBJECTIVE

This study was undertaken to (1) describe the cardiac structure and function and (2) to quantify the relationships between 25-hydroxyvitamin D [25(OH)D] and echocardiographic parameters in female basketball players.

DESIGN

A cross-sectional experimental design.

SETTING

Controlled laboratory setting.

PARTICIPANTS

Professional, female basketball players (n = 18).

INTERVENTION

25(OH)D and echocardiographic screening at the midpoint of the in-season phase, over a 2-week period in late Fall.

MAIN OUTCOME MEASURES

25(OH)D and echocardiographic parameters.

RESULTS

A high prevalence of vitamin D insufficiency was observed in the female players examined (77.8%), with most also displaying eccentric cardiac hypertrophy (77.8%). Nonsignificant, moderate correlations were found between 25(OH)D and structural echocardiographic parameters, including left atrium diameter (r = 0.34, P = 0.16), left ventricular (LV) end-systolic diameter (r = -0.46, P = 0.06), posterior wall thickness (r = 0.36, P = 0.14), LV mass (r = 0.30, P = 0.23), and LV index (r = 0.33, P = 0.18). Significant, large correlations were found between 25(OH)D and echocardiographic parameters indicative of systolic function, including LV ejection fraction (r = 0.59, P = 0.01), fractional shortening (r = 0.59, P = 0.01), and peak systolic mitral tissue velocity (r = 0.51, P = 0.003). Similarly, a significant, large correlation was found between 25(OH)D and diastolic function as indicated by mitral valve inflow deceleration time (r = 0.51, P = 0.03).

CONCLUSIONS

Our findings suggest the importance of female basketball players maintaining 25(OH)D concentration, given its possible physiological benefits on cardiac structure and function.

Differentiating Physiology from Pathology: The Gray Zones of the Athlete's Heart

Routine vigorous exercise can lead to electrical, structural, and functional adaptations that can enhance exercise performance. There are several factors that determine the type and magnitude of exercise-induced cardiac remodeling (EICR) in trained athletes. In some athletes with pronounced cardiac remodeling, there can be an overlap in morphologic features with mild forms of cardiomyopathy creating gray zone scenarios whereby distinguishing health from disease can be difficult. An integrated clinical approach that factors athlete-specific characteristics (sex, size, sport, ethnicity, and training history) and findings from multimodality imaging are essential to help make this distinction.

Exercise and the Female Heart

Female participation in sport has increased sharply during the last few decades, and for the third straight Olympic Games, there were more women than men on the US roster for the 2020 Tokyo Games. Given this, an understanding of the differences between men and women with respect to exercise-induced cardiac remodeling is critical for those caring for female athletes. Recent studies have provided insight into female-specific cardiac remodeling and have enhanced our understanding on the upper limits of cardiac remodeling in female athletes and how these adaptations compare with sedentary females, male athletes, and cardiomyopathies. Female athletes display fewer signs of adaptive remodeling on ECG compared with male athletes. Structurally, male athletes have larger absolute cardiac dimensions, but female athletes have similar or larger chamber size when adjusted for body size. Female athletes have a lower incidence of sudden cardiac arrest or death compared with male athletes in the early competitive years (high school, college, and professional) and in the masters athlete years. In addition, female athletes are less likely to have coronary disease and atrial fibrillation compared with male athletes. Data on longevity indicate that female athletes live longer than their sedentary counterparts. Unlike men, there has been no convincing association of extreme exercise and cardiovascular disease in longer-term endurance female athletes. The underlying mechanisms of these sex-based differences are not very well understood, and future studies are warranted to better understand the mechanisms of cardiac adaptation in female athletes.

Combined Non-Invasive Cardiac Imaging and Genetic Testing of Elite Volleyball Players: A Ten-Year Experience

Sudden cardiac death in athletes is a devastating event. Although significant progress has been made in identifying the underlying pathophysiology and genetic basis for sudden cardiac death in young athletes, controversy exists regarding cost-effective screening measures to identify at-risk individuals. In this report we describe our ten-year experience performing cardiovascular assessments on 150 members of the United States Men’s and Women’s National Volleyball teams. Through a combination of history, physical, echocardiography and genetic testing, we have identified one previously undiagnosed athlete with Marfan syndrome, along with four others with a possible aortopathy. Taken together, this approach is a cost-effective strategy for the identification of at-risk tall athletes leading to potentially lifesaving interventions, and raises the issue of the feasibility of screening for all tall individuals.

Exercise-Induced Cardiovascular Adaptations and Approach to Exercise and Cardiovascular Disease: JACC State-of-the-Art Review

The role of the sports cardiologist has evolved into an essential component of the medical care of athletes. In addition to the improvement in health outcomes caused by reductions in cardiovascular risk, exercise results in adaptations in cardiovascular structure and function, termed exercise-induced cardiac remodeling. As diagnostic modalities have evolved over the last century, we have learned much about the healthy athletic adaptation that occurs with exercise. Sports cardiologists care for those with known or previously unknown cardiovascular conditions, distinguish findings on testing as physiological adaptation or pathological changes, and provide evidence-based and "best judgment" assessment of the risks of sports participation. We review the effects of exercise on the heart, the approach to common clinical scenarios in sports cardiology, and the importance of a patient/athlete-centered, shared decision-making approach in the care provided to athletes.

Left atrial enlargement in competitive athletes and atrial electrophysiology

INTRODUCTION AND OBJECTIVES

There are scarce data on left atrial (LA) enlargement and electrophysiological features in athletes.

METHODS

Multicenter observational study in competitive athletes and controls. LA enlargement was defined as LA volume indexed to body surface area ≥ 34mL/m². We analyzed its relationship with atrial electrocardiography parameters.

RESULTS

We included 356 participants, 308 athletes (mean age: 36.4±11.6 years) and 48 controls (mean age: 49.3±16.1 years). Compared with controls, athletes had a higher mean LA volume index (29.8±8.6 vs 25.6±8.0mL/m², P=.006) and a higher prevalence of LA enlargement (113 [36.7%] vs 5 [10.4%], P <.001), but there were no relevant differences in P-wave duration (106.3±12.5ms vs 108.2±7.7ms; P=.31), the prevalence of interatrial block (40 [13.0%] vs 4 [8.3%]; P=.36), or morphology-voltage-P-wave duration score (1.8±0.84 vs 1.5±0.8; P=.71). Competitive training was independently associated with LA enlargement (OR, 14.7; 95%CI, 4.7-44.0; P <.001) but not with P-wave duration (OR, 1.02; 95%CI, 0.99-1.04), IAB (OR, 1.4; 95%CI, 0.7-3.1), or with morphology-voltage-P-wave duration score (OR, 1.4; 95%CI, 0.9-2.2).

CONCLUSIONS

LA enlargement is common in adult competitive athletes but is not accompanied by a significant modification in electrocardiographic parameters.

Cardiac Structure and Function in Elite Female and Male Soccer Players

Importance

Population-specific normative data are essential for the evaluation of competitive athletes. At present, there are limited data defining normal electrocardiographic (ECG) and echocardiographic values among elite US soccer players.

Objective

To describe ECG and echocardiographic findings in healthy elite US soccer players.

Design, Setting, and Participants

This cross-sectional study analyzed Fédération Internationale de Football Association-mandated screening sessions performed at US Soccer National Team training locations from January 2015 to December 2019. US women's and men's national team soccer players undergoing mandated cardiovascular screening were included.

Main Outcomes and Measures

Normal training-related and abnormal ECG findings were reported using the International Recommendations for Electrocardiographic Interpretation in Athletes. Echocardiographic measurements of structural and functional parameters relevant to cardiovascular remodeling were assessed relative to American Society of Echocardiography guideline-defined normal ranges.

Results

A total of 238 athletes (122 [51%] female; mean [SD] age, 20 [4] years; age range, 15-40 years) were included. Male athletes demonstrated a higher prevalence of normal training-related ECG findings, while female athletes were more likely to have abnormal ECG patterns (14 [11%] vs 0 in male cohort), largely accounted for by abnormal T-wave inversions. Echocardiography revealed no pathologic findings meeting criteria for sport restriction, but athletes frequently exceeded normal ranges for structural cardiac parameters responsive to exercise-induced remodeling including body surface area-indexed left ventricular (LV) mass (58 of 113 female athletes [51%] and 67 of 114 male athletes [59%]), indexed LV volume (89 of 115 female athletes [77%] and 76 of 111 male athletes [68%]), and LV wall thickness (37 of 122 female athletes [30%] and 47 of 116 male athletes [41%]). Age-stratified analysis revealed age-dependent increases in LV wall thickness, mass, and volumes among female athletes and LV wall thickness and mass among male athletes.

Conclusions and Relevance

These data represent the first set of comprehensive normative values for elite US soccer players and one of the largest sport-specific echocardiographic remodeling studies in female athletes. Abnormal ECG findings were more common in female athletes, while both female and male athletes frequently exceeded clinical normality cut points for remodeling-associated echocardiographic parameters.