Athlete's Heart vs. Cardiac Pathology
Clinical Approaches
Echo Florida 2012
Aaron L. Baggish MD
Cardiovascular Performance Program
Cardiac Ultrasound Laboratory
Division of Cardiology
Massachusetts General Hospital
Boston, MA
Assistant Professor of Medicine, HMS
Conflicts of Interest:
None
Disclosures / Funding:
American Heart Association
American Society of Echocardiography
CIMIT
NIH / NIDA
Athlete’s Heart: Clinical Relevance
1950’s
BMI = 23.8
2000’s
BMI = 27.6
2000’s
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The Athlete in CV Medicine
Where do they come from and Why?
Sudden
Death
The Athlete
Asymptomatic
Athlete’s Heart
Vs.
Pathology
Symptomatic
Syncope
Arrhythmias
ASHD
HTN
↓ Stamina
Athlete’s Heart: Care of the Athlete
The Athlete
Asymptomatic
or Symptomatic
•Pre-participation screening
•Insurance physicals
•“Well checks”
•Pre-operative assessment
Athlete’s Heart
Vs.
Pathology
•Risk factors assessment visits
Cardiac Remodeling: Health vs. Disease
Hemodynamic Stress of Sport
Pathophysiology of Disease
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Cardiac Remodeling: Physiology
Classic concept of LV remodeling……
Aortic
Regurgitation
Aortic
Stenosis
Pressure Challenge
Volume Challenge
Cardiac Remodeling: Physiology
Endurance Activities
Sustained ↑ CO
• 4 to 5 times rest
• ↑ ↑ ↑ HR & ↑ SV
• Vasodilation
Volume Challenge
Strength Activities
Repetitive↑ SBP
• Systolic BP > 200 mmHg
• Skeletal Mus. Contraction
• Vasoconstriction
Pressure Challenge
Cardiac Remodeling: Physiology
Annals of Int Med 1975;82:521
3
Cardiac Remodeling: Physiology
Weiner. Prog Cardio Vasc Dis. 2012
Cardiac Remodeling: Physiology
Can we separate athletic remodeling from pathology using
using echo?
YES (>95% of the time)……IF…..
We know what is normal and remain focused on what the
clinical question is?
The Gray Zone: Health vs. Disease
The 3 Cardinal Forms of Clinical Uncertainty
Left Chamber Dilation
Right Chamber Dilation
Myocardial Thickening
Physiologic
Eccentric LVH
Physiologic
RV Dilation
Physiologic
Concentric LVH
ARVC
Exercise RVC (?)
HCM
Hypertensive CMP
Non-compaction
Infiltrative CMP
Familial DCM
Idiopathic DCM
Toxic DCM
Valvular Heart Disease
4
Evaluation “Tool Kit”
Understanding of Exercise-Induced
Cardiac Remodeling
Medical History &
Physical Examination
12-Lead ECG
2D-Echocardiography
Cardiac
MRI
Advanced
TTE
Imaging
Exercise
Testing
(+/- Imaging)
Ambulatory
Rhythm
Monitoring
Genetic
Testing
Prescribed
Detraining
Uncertainty #1: LV Chamber Enlargement
Physiologic:
Normal Structure
Expected with Endurance or
Mixed Hemodynamic Training
Accompanied by Proportionate Increase in
LV Wall Thickening
(Symmetric Eccentric LVH)
Accompanied by normal to low normal
resting LVEF (~ 50%)
Left Chamber Dilation
TDI / Strain assessment with preserved or
enhanced function
Accompanied “other” chamber enlargement
(RV, LA)
Uncertainty #1: LV Chamber Enlargement
~40% of male athletes
Pelliccia et al. Annals of Int Med 1999
5
Uncertainty #1: LV Chamber Enlargement
25% of US college athletes exceed
gender recommended LVIDd limit
Weiner et al. JASE 2012
Uncertainty #1: LV Chamber Enlargement
BMJ 2012
Am J Physiol. 2008
Uncertainty #1: LV Chamber Enlargement
Physiologic vs. Pathologic
Normal Structure
Eccentric LVH NOT isolated chamber dilation
Accompanied RV and LA chamber enlargement
LVIDd “cut-offs” are not helpful
“Lowish” resting LVEF with normal or enhanced
LV mechanics is physiology
Left Chamber Dilation
If in doubt, exercise testing is VERY useful: to
confirm LV augmentation and to document
supranormal exercise capacity
This is not an HCM mimicker
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Uncertainty #2: RV Chamber Enlargement
Physiologic:
Normal Structure
Expected with Endurance or
Mixed Hemodynamic Training
Global RV process without sacculation,
aneurysmal dilation, segmental dysfunction,
or fibrosis (?)
Accompanied by concomitant LV
enlargement but no RVH
Right Chamber Dilation
Accompanied by normal to low normal
resting FAC / RVEF (~ 45%)
TDI / Strain assessment with preserved or
enhanced function
Uncertainty #2: RV Chamber Enlargement
D’Andrea et al. IJC 2011
Uncertainty #2: RV Chamber Enlargement
Oxborough et al. JASE 2012
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Uncertainty #2: RV Chamber Enlargement
Uncertainty #2: RV Chamber Enlargement
Whyte et al. JAP 2011
ExerciseInduced CMP
???
LaGerche et al. EHJ 2011
Uncertainty #2: RV Chamber Enlargement
Physiologic vs. Pathologic
Normal Structure
RV dimensions “cut-offs” are not helpful
“Always” associated with LV remodeling
Global dilation with low normal function is physiologic
if not associated with:
-Structural ARVC features (sacc., trabec., M.B.)
-Functional ARVC features (segmental dysf.)
-ECG and saECG criteria for ARVC
Right Chamber Dilation
If in doubt, comprehensive exercise test and rhythm
monitoring
Isolated finding of fibrosis…more work needed?
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Uncertainty #3: Thick LV Walls
Physiologic:
Normal Structure
Least frequent but most problematic issue
Expected with strength (isometric) training
Mild symmetric concentric LVH
Accompanied by no changes……
“south of the mitral valve”
Accompanied by normal to hyperdynamic resting
LVEF (>60%)
Myocardial Thickening
Marked regional thickening not physiologic until
proven otherwise!
Uncertainty #3: Thick LV Walls
Adult Athletes
Pellicia et al NEJM 1991
Junior Athletes
Sharma et al JACC 2002
Uncertainty #3: Thick LV Walls
Not a single healthy college athlete
with walls > 14
Weiner et al. JASE 2012
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Uncertainty #3: LV Thick Walls
Prescribed Detraining
5 published studies
All eccentric LVH
Plasticity proven
Concentric LVH ??
Weiner JACC 2012
Uncertainty #3: Thick LV Walls
Physiologic vs. Pathologic
Normal Structure
Physiologic concentric LVH is symmetric w/o regional
variation….marked assymmetry is pathology until
proven otherwise
Wall thickness “cut-offs” are VERY helpful
Accurate absolute thicknesses > 15 are pathologic
until proven otherwise
Myocardial Thickening
Exercise testing (CPET) is a very useful discriminator
Detraining may be necessary to arrive at a final Dx
The Gray Zone: Health vs. Disease
The 3 Cardinal Forms of Clinical Uncertainty
Left Chamber Dilation
Right Chamber Dilation
Myocardial Thickening
Physiologic
Eccentric LVH
Physiologic
RV Dilation
Physiologic
Concentric LVH
ARVC
Exercise RVC (?)
HCM
Hypertensive CMP
Non-compaction
Infiltrative CMP
Familial DCM
Idiopathic DCM
Toxic DCM
Valvular Heart Disease
10
Thank You !
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