Understanding Athlete's Heart vs Cardiac Pathology
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A presentation on Athlete's Heart by Dr Abhinav Luhach BSc (Med), MBBS (Hons1), FRACP.
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Understanding Athlete's Heart vs Cardiac Pathology
- 2. Athlete's Heart Abhinav Luhach BSc (Med), MBBS (Hons1), FRACP
- 3. Athlete's Heart • Regular physical activity leads to physiological adaptations in cardiac dimensions • This remodelling affects primarily LV wall thickness and cavity size • May be reflected on changes in ECG & echo
- 4. Athlete's Heart • Permits enhanced filling of the left ventricle in diastole • Augmentation of stroke volume allowing generation of a large cardiac output even at rapid heart rates • As a consequence, a diagnostic dilemma can arise when attempting to differentiate physiological adaptation with associated ECG and echo changes from true cardiac pathology
- 6. Dilemma • False-positive diagnoses may lead to erroneous disqualification from a sport with significant psychological distress and loss of earnings Vs • False-negative evaluations may result in devastating SCD.
- 7. Screening • Pre-participation cardiovascular screening of athletes is recommended by both the American Heart Association and the European Society of Cardiology • Evaluation of symptoms, family history, and physical examination is recommended • Role of ECG remains controversial
- 9. Role of ECG • Incorporating ECG into a screening protocol improves efficacy in identifying conditions capable of causing SCD. • Test of choice for electrical abnormalities – WPW, LQTS & Brugada syndrome – Often abnormal in cardiomyopathies (HCM, ARVC) • Some evidence supports use of ECGs
- 10. ECG Findings in Athletes
- 11. ECG of an Athlete
- 13. Athlete's heart vs HCM • In athlete's heart left ventricular hypertrophy is generally mild (<12mm) & is symmetrical • However in some individual’s LVWT is between 13-15mm which represents a “grey zone” for considering HCM • ECG, echo and occasionally more sophisticated investigations enable differentiating between the 2 conditions
- 14. Athlete's heart vs HCM • ECG changes suggestive of HCM include: – T wave inversion – Pathological Q waves – LBBB – ST segment depression
- 15. Echo findings in athlete's heart vs HCM Suggestive of AH • Concentric LVH • LV cavity >55mm • Normal diastolic function Suggestive of HCM • Asymmetric LVH • LV cavity <45mm • Abnormal diastolic function • Mitral valve abnormalities
- 16. Pattern of Left Ventricular Hypertrophy
- 17. Supplementary Tools • In rare cases there may be a role for more detailed testing • Cardiac MRI – More accurate assessment of wall thickness – Late gadolinium enhancement after administering contrast • Functional exercise testing • Genetic testing • Re-evaluation after a period of deconditioning
- 18. Athlete’s Heart vs ARVC • Challenging!! • Features suggestive of ARVC – Epsilon waves – Non-sustained VT of LBBB pattern – Abnormal regional RV motion abnormalities • Cardiac MRI can be useful
- 19. ARVC
- 20. ECG in ARVC
- 22. Conclusion • Morphological and electrical changes in cardiac status of athletes can appear similar to pathological entities • Using a structured approach it is often possible to distinguish between these entities
Editor's Notes
- The finding of rapid ST elevation in V3–6 with an elevated J point and a peaked upright T wave (or more commonly in athletes of African descent, a domed ST segment followed by a biphasic or inverted T wave) is present in 50% of trained athletes. It is particularly prevalent in men. Of note, ECG changes of high voltage and abnormal repolarization can precede echocardiogram changes in hypertrophic cardiomyopathy. Although a normal echocardiogram in this setting (in the absence of other factors) may allow participation, such athletes should be followed up serially. In athletes, although the mechanism is uncertain, early repolarization seems to regress with age and when training declines and often changes or disappears during a bout of exercise or with increasing heart rate (suggesting potentially a vagally mediated or heart rate–sensitive mechanism). It is important to distinguish these findings from the Brugada-like ECG pattern that is recognized in V1–2.19
- > 3mm in depth, >40msec duration, exclude lead III, V1, aVR
- 8-12 wks
- Task force criteria