The athleteʼs heart and hypertrophic cardiomyopathy: two conditions which may be misdiagnosed and coexistent. Which parameters should be analysed to distinguish one disease from the other?

Clinical Anatomy and Medical Malpractice-A Narrative Review with Methodological Implications

Anatomical issues are intrinsically included in medico-legal methodology, however, higher awareness would be needed about the relevance of anatomy in addressing medico-legal questions in clinical/surgical contexts. Forensic Clinical Anatomy has been defined as "the practical application of Clinical Anatomy to the ascertainment and evaluation of medico-legal problems". The so-called individual anatomy (normal anatomy, anatomical variations, or anatomical modifications due to development, aging, para-physiological conditions, diseases, or surgery) may acquire specific relevance in medico-legal ascertainment and evaluation of cases of supposed medical malpractice. Here, we reviewed the literature on the relationships between anatomy, clinics/surgery, and legal medicine. Some methodological considerations were also proposed concerning the following issues: (1) relevant aspects of individual anatomy may arise from the application of methods of ascertainment, and they may be furtherly ascertained through specific anatomical methodology; (2) data about individual anatomy may help in the objective application of the criteria of evaluation (physio-pathological pathway, identification-evaluation of errors, causal value, damage estimation) and in final judgment about medical responsibility/liability. Awareness of the relevance of individual anatomy (risk of iatrogenic lesions, need for preoperative diagnostic procedures) should be one of the principles guiding the clinician; medico-legal analyses can also take advantage of its contribution in terms of ascertainment/evaluation.

Doping with anabolic androgenic steroids (AAS): Adverse effects on non-reproductive organs and functions

Since the 1970s anabolic androgenic steroids (AAS) have been abused at ever increasing rates in competitive athletics, in recreational sports and in bodybuilding. Exceedingly high doses are often consumed over long periods, in particular by bodybuilders, causing acute or chronic adverse side effects frequently complicated by additional polypharmacy. This review summarizes side effects on non-reproductive organs and functions; effects on male and female reproduction have been recently reviewed in a parallel paper. Among the most striking AAS side effects are increases in haematocrit and coagulation causing thromboembolism, intracardiac thrombosis and stroke as well as other cardiac disturbances including arrhythmias, cardiomyopathies and possibly sudden death. 17α-alkylated AAS are liver toxic leading to cholestasis, peliosis, adenomas and carcinomas. Hyperbilirubinaemia can cause cholemic nephrosis and kidney failure. AAS abuse may induce exaggerated self-confidence, reckless behavior, aggressiveness and psychotic symptoms. AAS withdrawal may be accompanied by depression and suicidal intentions. Since AAS abuse is not or only reluctantly admitted physicians should be aware of the multitude of serious side effects when confronted with unclear symptoms.

Cardiovascular health, part 1: preparticipation cardiovascular screening

CONTEXT

Identification of potentially fatal cardiac conditions in otherwise healthy athletes presents a major challenge to the sports medicine community. The requirements for preparticipation screening vary among countries and even from state to state within the United States. The mandated use of an electrocardiogram as a screening implement has provoked international controversy.

EVIDENCE ACQUISITION

Part 1 of this review highlights the current guidelines and controversies surrounding cardiovascular screening, with a focus on the diagnostic challenges associated with identifying athletes with inheritable cardiomyopathies. Data sources were limited to peer-reviewed publications from 1984 to the present.

RESULTS

Preparticipation screening should include at least a history and a physical examination for all athletes, whereas use of an electrocardiogram is still controversial. Diagnosis of inherited cardiomyopathies presents unique challenges, particularly in hypertrophic cardiomyopathy, where many features can mimic those found in the "athlete's heart."

CONCLUSIONS

Recognizing cardiac conditions in athletes that can predispose them to sudden cardiac death or other adverse outcomes is of vital importance, as is the appropriate exclusion of these athletes from competition. Further studies are needed to determine the most efficient and cost-effective means of screening and to increase the sensitivity and specificity of diagnostic testing for inheritable cardiovascular diseases.

Echocardiography in patients with hypertrophic cardiomyopathy: usefulness of old and new techniques in the diagnosis and pathophysiological assessment

Hypertrophic cardiomyopathy (HCM) is one of the most common inherited cardiomyopathy. The identification of patients with HCM is sometimes still a challenge. Moreover, the pathophysiology of the disease is complex because of left ventricular hyper-contractile state, diastolic dysfunction, ischemia and obstruction which can be coexistent in the same patient. In this review, we discuss the current and emerging echocardiographic methodology that can help physicians in the correct diagnostic and pathophysiological assessment of patients with HCM.

Myocardial adaptation and efficiency in response to intensive physical training in elite speedskaters

BACKGROUND

Physiological cardiac adaptations to exercise training resulting in the 'athlete's heart' are well known. Most of these studies, however, were included either those who exercise to exhaustion, non-elite athletes or those who participate primarily in sports requiring extensive weight training. Studies utilizing conventional and tissue Doppler echocardiographic studies in highly competitive elite athletes whose training includes both aerobic and weight training are limited.

AIMS AND METHODS

1) To identify baseline cardiovascular structural and physiologic adaptations present in elite athletes who participate in both endurance aerobic and weight training programs and to compare them to similarly aged sedentary controls. The population includes 24 speedskaters participating in the 2006 Olympic Games and 15 sedentary young subjects. 2) To evaluate possible structural and physiologic cardiac changes following short duration, vigorous exercise. We repeated the baseline echocardiographic protocol in the athletes following a 3000 m sprint conducted at race pace.

RESULTS

Compared to non-athletes, the atrial and left ventricular (LV) volumes at rest were larger in elite athletes. There was enhanced LV diastolic function as manifested by higher early annular (septal and lateral) tissue Doppler velocities (E'): 12.7+/-2.3 vs 11.3+/-1.1 cm/s and 17.4+/-4.7 vs 14.4+/-1.2 cm/s, P=0.025 and 0.020 respectively. Evidence of right ventricular (RV) remodeling included larger basal RV dimensions (38+/-5 vs 32+/-4 mm, P=0.001), attenuated RV systolic function at rest (RV area change 35+/-13% in athletes vs 47+/-11% in controls, P=0.006) and lower RV systolic strain rate (SSR) 1.9+/-0.5 vs 2.9+/-1.1/s, P<0.001). However, there was better right ventricular (RV) diastolic function at rest, E': 13.5+/-3.6 vs 11.1+/-1.5 cm/s (P=0.016). Following exercise, the athletes exhibited augmentation of RV systolic function with increased RV fractional area change (increasing to 43+/-10%, P=0.007) and SSR (2.5+/-1.2/s post-exercise, P=0.038).

CONCLUSION

Participation by world-class speedskaters in a vigorous training regimen results in cardiovascular anatomic and physiologic adaptations. These changes, including cardiac chamber dilatation, enhanced ventricular diastolic function and attenuated resting RV systolic function, are likely adaptive and allow for more efficient energy use at rest and a robust response to demands of exercise.

The upper limit of physiological cardiac hypertrophy in elite male and female athletes in China

Physiological hypertrophy in response to physical training is important in the differentiation of physiological and pathological left ventricular hypertrophy. The goal of our study was to define the structural characteristics of the heart in Chinese athletes. Between June 2005 and August 2005, 339 (165 male, 174 female) elite Chinese athletes from 19 sports were profiled. Standard two-dimensional guided M-mode and Doppler echocardiography were employed to evaluate left ventricular morphology and function. Of the 165 male athletes, 19 (11.5%) male athletes presented with an LVIDd>or=60 mm, with an upper limit of 65 mm. Only three male athletes presented with wall thickness values>or=13 mm. Eighteen (10.3%) female athletes presented with an LVIDd>or=50 mm, and seven (4.2%) female athletes presented with an LVIDd>or=55 mm, with an upper limit of 62 mm. None were found to have a maximum wall thickness greater than 11 mm. Systolic and diastolic functions were within normal limits for all athletes. Results from the present study suggest that upper normal limits for left ventricular wall thickness and LVIDd are 14 and 65 mm for elite male Chinese athletes, and 11 mm and 62 mm for elite female Chinese athletes. Values in excess of these should be viewed with caution and should prompt further investigation to identify the underlying mechanism for the observed left ventricular hypertrophy.

Cardiac magnetic field map topology quantified by Kullback-Leibler entropy identifies patients with hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a common primary inherited cardiac muscle disorder, defined clinically by the presence of unexplained left ventricular hypertrophy. The detection of affected patients remains challenging. Genetic testing is limited because only in 50%-60% of all HCM diagnoses an underlying mutation can be found. Furthermore, the disease has a varied clinical course and outcome, with many patients having little or no discernible cardiovascular symptoms, whereas others develop profound exercise limitation and recurrent arrhythmias or sudden cardiac death. Therefore prospective screening of HCM family members is strongly recommended. According to the current guidelines this includes serial echocardiographic and electrocardiographic examinations. In this study we investigated the capability of cardiac magnetic field mapping (CMFM) to detect patients suffering from HCM. We introduce for the first time a combined diagnostic approach based on map topology quantification using Kullback-Leibler (KL) entropy and regional magnetic field strength parameters. The cardiac magnetic field was recorded over the anterior chest wall using a multichannel-LT-SQUID system. CMFM was calculated based on a regular 36 point grid. We analyzed CMFM in patients with confirmed diagnosis of HCM (HCM, n=33, 43.8+/-13 years, 13 women, 20 men), a control group of healthy subjects (NORMAL, n=57, 39.6+/-8.9 years; 22 women and 35 men), and patients with confirmed cardiac hypertrophy due to arterial hypertension (HYP, n=42, 49.7+/-7.9 years, 15 women and 27 men). A subgroup analysis was performed between HCM patients suffering from the obstructive (HOCM, n=19) and nonobstructive (HNCM, n=14) form of the disease. KL entropy based map topology quantification alone identified HCM patients with a sensitivity of 78.8% and specificity of 86.9% (overall classification rate 84.8%). The combination of the KL parameters with a regional field strength parameter improved the overall classification rate to 87.9% (sensitivity: 84.8%, specificity: 88.9%, area under ROC curve: 0.94). KL measures applied to discriminate between HOCM and HNCM patients showed a correct classification of 78.8%. The combination of one KL and one regional parameter again improved the overall classification rate to 97%. A preliminary prospective analysis in two HCM families showed the feasibility of this diagnostic approach with a correct diagnosis of all 22 screened family members (1 HOCM, 4 HNCM, 17 normal). In conclusion, Cardiac Magnetic Field Mapping including KL entropy based topology quantifications is a suitable tool for HCM screening.