The Role of Cardiovascular Magnetic Resonance Imaging in the Assessment of Myocardial Fibrosis in Young and Veteran Athletes: Insights From a Meta-Analysis

Myocardial Fibrosis in Young and Veteran Athletes: Evidence from a Systematic Review of the Current Literature

Background: Exercise is associated with several cardiac adaptations that can enhance one's cardiac output and allow one to sustain a higher level of oxygen demand for prolonged periods. However, adverse cardiac remodelling, such as myocardial fibrosis, has been identified in athletes engaging in long-term endurance exercise. Cardiac magnetic resonance (CMR) imaging is considered the noninvasive gold standard for its detection and quantification. This review seeks to highlight factors that contribute to the development of myocardial fibrosis in athletes and provide insights into the assessment and interpretation of myocardial fibrosis in athletes. Methods: A literature search was performed using the PubMed/Medline database and Google Scholar for publications that assessed myocardial fibrosis in athletes using CMR. Results: A total of 21 studies involving 1642 endurance athletes were included in the analysis, and myocardial fibrosis was found in 378 of 1595 athletes. A higher prevalence was seen in athletes with cardiac remodelling compared to control subjects (23.7 vs. 3.3%, p < 0.001). Similarly, we found that young endurance athletes had a significantly higher prevalence than veteran athletes (27.7 vs. 19.9%, p < 0.001), while male and female athletes were similar (19.7 vs. 16.4%, p = 0.207). Major myocardial fibrosis (nonischaemic and ischaemic patterns) was predominately observed in veteran athletes, particularly in males and infrequently in young athletes. The right ventricular insertion point was the most common fibrosis location, occurring in the majority of female (96%) and young athletes (84%). Myocardial native T1 values were significantly lower in athletes at 1.5 T (p < 0.001) and 3 T (p = 0.004), although they had similar extracellular volume values to those of control groups. Conclusions: The development of myocardial fibrosis in athletes appears to be a multifactorial process, with genetics, hormones, the exercise dose, and an adverse cardiovascular risk profile playing key roles. Major myocardial fibrosis is not a benign finding and warrants a comprehensive evaluation and follow-up regarding potential cardiac disease.

Late Gadolinium Enhancement in Early Repolarization Syndrome

BACKGROUND

In patients with Brugada syndrome, myocardial fibrosis can be identified through epicardial biopsy or cardiac magnetic resonance imaging (CMR) with late gadolinium enhancement (LGE). However, the myocardial alterations in patients with early repolarization syndrome (ERS) remain poorly elucidated.

OBJECTIVE

To investigate the presence of myocardial fibrosis in patients with ERS using LGE in CMR.

METHODS

We retrospectively evaluated 20 ERS patients, all of whom exhibited J waves in the contiguous two leads. The location of J waves was classified as in the septum (V1-V2), anterior (V3-V4), lateral (I, aVL, V5-V6), inferior (II, III, aVF), or posterior (V7-V9) regions. To compare the distribution of LGE in CMR with J waves, sections of short-axis view of left ventricle (LV) were categorized as located in either the septum, anterior, lateral, inferior, and posterior regions.

RESULTS

Overall, 85% of ERS patients displayed LGE, which was more prevalent in the septum and posterior regions, followed by the inferior and lateral regions. The presences or absence of J waves and LGE coincided in 61% of LV areas, while discordance between the distributions of J waves and LGE was observed in 38%. LGE was most frequent in the septum (75%), where its reflection in J waves may be less robust. The appearance of LGE was not associated with symptoms, electrical storm, or VF occurrence during follow-up.

CONCLUSIONS

LGE is common among patients with ERS, and the distribution of J waves and LGE coincides in approximately sixty percent of LV areas.

Prevalence of Abnormal Cardiovascular Magnetic Resonance Findings in Athletes Recovered from COVID-19 Infection: A Systematic Review and Meta-Analysis

Background: Competitive sports and high-level athletic training result in a constellation of changes in the myocardium that comprise the 'athlete's heart'. With the spread of the COVID-19 pandemic, there have been concerns whether elite athletes would be at higher risk of myocardial involvement after infection with the virus. This systematic review and meta-analysis evaluated the prevalence of abnormal cardiovascular magnetic resonance (CMR) findings in elite athletes recovered from COVID-19 infection. Methods: The PubMed, Cochrane and Web of Science databases were systematically search from inception to 15 November 2023. The primary endpoint was the prevalence of abnormal cardiovascular magnetic resonance findings, including the pathological presence of late gadolinium enhancement (LGE), abnormal T1 and T2 values and pericardial enhancement, in athletes who had recovered from COVID-19 infection. Results: Out of 3890 records, 18 studies with a total of 4446 athletes were included in the meta-analysis. The pooled prevalence of pathological LGE in athletes recovered from COVID-19 was 2.0% (95% CI 0.9% to 4.4%, I2 90%). The prevalence of elevated T1 and T2 values was 1.2% (95% CI 0.4% to 3.6%, I2 87%) and 1.2% (95% CI 0.4% to 3.7%, I2 89%), respectively, and the pooled prevalence of pericardial involvement post COVID-19 infection was 1.1% (95% CI 0.5% to 2.5%, I2 85%). The prevalence of all abnormal CMR findings was much higher among those who had a clinical indication of CMR. Conclusions: Among athletes who have recently recovered from COVID-19 infection, there is a low prevalence of abnormal CMR findings. However, the prevalence is much higher among athletes with symptoms and/or abnormal initial cardiac screening. Further studies and longer follow up are needed to evaluate the clinical relevance of these findings and to ascertain if they are associated with adverse events.

Low rates of myocardial fibrosis and ventricular arrhythmias in recreational athletes after SARS-CoV-2 infection

Introduction

High rates of cardiac involvement were reported in the beginning of the coronavirus disease 2019 (COVID-19) pandemic. This led to anxiety in the athletic population. The current study was set up to assess the prevalence of myocardial fibrosis and ventricular arrhythmias in recreational athletes with the recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Methods

Consecutive adult recreational athletes (≥18 years old, ≥4 h of mixed type or endurance sports/week) underwent systematic cardiac evaluation after a prior confirmed COVID-19 infection. Evaluation included clinical history, electrocardiogram (ECG), 5-day Holter monitoring, and cardiac magnetic resonance (CMR) imaging with simultaneous measurement of high-sensitive cardiac Troponin I. Data from asymptomatic or mildly symptomatic athletes (Group 1) were compared with those with moderate to severe symptoms (Groups 2-3). Furthermore, a comparison with a historical control group of athletes without COVID-19 (Master@Heart) was made.

Results

In total, 35 athletes (18 Group 1, 10 female, 36.9 ± 2.2 years, mean 143 ± 20 days following diagnosis) were evaluated. The baseline characteristics for the Group 1 and Groups 2-3 athletes were similar. None of the athletes showed overt myocarditis on CMR based on the updated Lake Louise criteria for diagnosis of myocarditis. The prevalence of non-ischemic late gadolinium enhancement [1 (6%) Group 1 vs. 2 (12%) Groups 2-3; p = 0.603] or ventricular arrhythmias [1 Group 1 athlete showed non-sustained ventricular tachycardia (vs. 0 in Groups 2-3: p = 1.000)] were not statistically different between the groups. When the male athletes were compared with the Master@Heart athletes, again no differences regarding these criteria were found.

Conclusion

In our series of recreational athletes with prior confirmed COVID-19, we found no evidence of ongoing myocarditis, and no more detection of fibrosis or ventricular arrhythmias than in a comparable athletic pre-COVID cohort. This points to a much lower cardiac involvement of COVID-19 in athletes than originally suggested.

Can the Heart Get an Overuse Sports Injury?

Can the Heart Get an Overuse Sports Injury?Recent studies suggest that vigorous endurance exercise increases markers of cardiomyocyte injury and that lifelong endurance exercise may increase myocardial scarring, coronary artery atherosclerosis, AF, and aortic dilatation. This review summarizes the evidence linking these conditions with physical exertion and an approach to their management.

[Sports cardiology : Which sport can be recommended for heart diseases?]

Innerhalb der Kardiologie hat der Bereich der Sportkardiologie in den letzten 10 Jahren sukzessive an Bedeutung zugenommen. Dies liegt v. a. daran, dass sich das Spektrum der Fragestellungen zu körperlichem Training in der Prävention und Sekundärprävention jenseits der klassischen kardiovaskulären Rehabilitation erweitert hat. Dieses Spektrum betrifft v. a. Jugendliche und junge Erwachsene, die bei manifester kardialer Erkrankung weiterhin körperlich aktiv sein wollen und zum Teil Freizeit- und Leistungssport anstreben. Ergänzend wird der Kreis der Patient*innen mit kardialen Erkrankungen, die auch noch im höheren Alter sportliche Höchstleistungen anstreben und Beratung suchen, immer größer. In diesen Fällen geht es dann darum, auf der einen Seite ein körperliches Training als Therapiestrategie zu empfehlen, aber auf der anderen Seite auch das kardiovaskuläre System zu schützen. Empfehlungen zu körperlichem Training sollten deshalb auch individuelle Aspekte berücksichtigen. Zusätzlich wird im ambitionierten Freizeit- und Leistungssport die Empfehlung zur Freigabe von Wettkampfsport adressiert. So fragen Patient*innen nach Sport- und Trainingsempfehlungen bei kardiovaskulären Risikofaktoren wie arterieller Hypertonie, Pathologien der Koronararterien im Sinne des Fehlabgangs der Koronarien, Muskelbrücke oder koronarer Herzkrankheit, Kardiomyopathien, Myokarditis sowie Herzrhythmusstörungen und Herzklappenfehlern. In diesem Artikel werden diese Erkrankungen mit entsprechenden sportkardiologischen Spezifika diskutiert und jeweils Empfehlungen zu körperlichem Training und Wettkampfsport gegeben.

The Athlete's Heart-Challenges and Controversies: JACC Focus Seminar 4/4

Regular exercise promotes structural, functional, and electrical remodeling of the heart, often referred to as the "athlete's heart," with intense endurance sports being associated with the greatest degree of cardiac remodeling. However, the extremes of exercise-induced cardiac remodeling are potentially associated with uncommon side effects. Atrial fibrillation is more common among endurance athletes and there is speculation that other arrhythmias may also be more prevalent. It is yet to be determined whether this arrhythmic susceptibility is a result of extreme exercise remodeling, genetic predisposition, or other factors. Gender may have the greatest influence on the cardiac response to exercise, but there has been far too little research directed at understanding differences in the sportsman's vs sportswoman's heart. Here in part 4 of a 4-part seminar series, the controversies and ambiguities regarding the athlete's heart, and in particular, its arrhythmic predisposition, genetic, and gender influences are reviewed in depth.

Exercise-induced myocardial edema in master triathletes: Insights from cardiovascular magnetic resonance imaging

Background

Strenuous exercise has been associated with functional and structural cardiac changes due to local and systemic inflammatory responses, reflecting oxidative, metabolic, hormonal, and thermal stress, even in healthy individuals. We aimed to assess changes in myocardial structure and function using cardiovascular magnetic resonance (CMR) imaging in master triathletes early after a full-distance Ironman Triathlon race.

Materials and methods

Ten master triathletes (age 45 ± 8 years) underwent CMR within 3 h after a full-distance Ironman Triathlon race (3.8 km swimming, 180 km cycling, and 42.2 km running) completed with a mean time of 12 ± 1 h. All the triathletes had a 30-day follow-up CMR. Cine balanced steady-state free precession, T2-short tau inversion recovery (STIR), tagging, and late gadolinium enhancement (LGE) imaging sequences were performed on a 1.5-T MR scanner. Myocardial edema was defined as a region with increased T2 signal intensity (SI) of at least two SDs above the mean of the normal myocardium. The extent of myocardial edema was expressed as the percentage of left ventricular (LV) mass. Analysis of LV strain and torsion by tissue tagging included the assessment of radial, longitudinal, and circumferential peak systolic strain, rotation, and twist.

Results

Compared with postrace, biventricular volumes, ejection fraction, and LV mass index remained unchanged at 30-day follow-up. Global T2 SI was significantly higher in the postrace CMR (postrace 10.5 ± 6% vs. follow-up 3.9 ± 3.8%, P = 0.004) and presented with a relative apical sparing distribution (P < 0.001) matched by reduction of radial peak systolic strain of basal segments (P = 0.003). Apical rotation and twist were significantly higher immediately after the competition compared with follow-up (P < 0.05).

Conclusion

Strenuous exercise in master triathletes is associated with a reversible regional increase in myocardial edema and reduction of radial peak systolic strain, both presenting with a relative apical sparing pattern.

Diagnostic evaluation and cardiopulmonary exercise test findings in young athletes with persistent symptoms following COVID-19

OBJECTIVES

Persistent or late-onset cardiopulmonary symptoms following COVID-19 may occur in athletes despite a benign initial course. We examined the yield of cardiac evaluation, including cardiopulmonary exercise testing (CPET), in athletes with cardiopulmonary symptoms after COVID-19, compared CPETs in these athletes and those without COVID-19 and evaluated longitudinal changes in CPET with improvement in symptoms.

METHODS

This prospective cohort study evaluated young (18-35 years old) athletes referred for cardiopulmonary symptoms that were present>28 days from COVID-19 diagnosis. CPET findings in post-COVID athletes were compared with a matched reference group of healthy athletes without COVID-19. Post-COVID athletes underwent repeat CPET between 3 and 6 months after initial evaluation.

RESULTS

Twenty-one consecutive post-COVID athletes with cardiopulmonary symptoms (21.9±3.9 years old, 43% female) were evaluated 3.0±2.1 months after diagnosis. No athlete had active inflammatory heart disease. CPET reproduced presenting symptoms in 86%. Compared with reference athletes (n=42), there was similar peak VO2 but a higher prevalence of abnormal spirometry (42%) and low breathing reserve (42%). Thirteen athletes (62%) completed longitudinal follow-up (4.8±1.9 months). The majority (69%) had reduction in cardiopulmonary symptoms, accompanied by improvement in peak VO2 and oxygen pulse, and reduction in resting and peak heart rate (all p<0.05).

CONCLUSION

Despite a high burden of cardiopulmonary symptoms after COVID-19, no athlete had active inflammatory heart disease. CPET was clinically useful to reproduce symptoms with either normal testing or identification of abnormal spirometry as a potential therapeutic target. Improvement in post-COVID symptoms was accompanied by improvements in CPET parameters.