Echo and the Athletes heart

April 5, 2013 Carol Chen, MD

No disclosures

Hank Gathers, 23, dies on court, HCM Thomas Herrion, 23, dies after game, HCM

Morosini, 25 yo soccer player, SCD

Flo Hyman, 31,dies on court, ruptured aorta (Marfan)

Causes of sudden death in athletes 19802005 (n=1435)

Maron, BJ Circulation 2007;115:1643

Common Causes of SCD in YOUNG athletes

J Am Coll Cardiol. 2013;61(10):1027-1040. doi:10.1016/j.jacc.2012.08.1032

Date of download: 3/28/2013

Copyright The American College of Cardiology. All rights reserved.

AHA consensus panel: 1996/2007 update

12-point pre-participation athletic screening: Medical history Personal history 1.Exertional chest pain/discomfort 2.Unexplained syncope/near syncope 3. Excessive exertional and unexplained dyspnea/fatigue 4. Prior recognition of a heart murmur 5. Elevated systemic BP Family history 6. Premature death (sudden) <age 50 due to heart disease 7. disability from heart disease in close relative <50yo 8. specific knowledge of cardiac conditions, HCM/DCM/LQTS, Marfan/arrhythmias
Physical examination 9.Heart Murmur (sitting / standing) 10. femoral pulses (r/o coarctation) 11. Marfan stigmata 12. BP in sitting position

ECG is not standard

Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol Consensus statement of the study group of sport cardiology of the Working Group of Cardiac Rehabilitation and exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology

European Heart Journal (2005) 26, 516-524

Since 1982, Italian government mandated annual ECG +H/P in all competitive athletes age 1235. IOC also mandates yearly EKGs and H/P in all Olympic participants.

Recommendations for interpretation of 12 lead ECG in athletes. Corrado et al EHJ (2010)31 (2):243-259

Common training ECG changes sinus brady PR prolongation Incomplete RBBB early repolarization isolated QRS voltage criteria for LVH Convex ST +T wave inv V1-V4 in black athletes Wenckebach Ectopic atrial rhythm Junctional escape rhythm

Uncommon- needs follow up T wave inversion ST depression pathologic Q LAE LAD/LAFB RAD/LPFB RVH pre-excitation LBBB/RBBB Long or short QT Brugada-like repol

For a free online training module on ECG interpretation in athletes, please visit: http://learning.bmj.com/ECGathlete

59% structural heart disease

Maron, BJ Circulation 2007;115:1643

Feasibility of screening portable echocardiography-JASE May 2012 Weiner et al. JASE 2012; 25(5) 568-575.
Harvard University Athletics program Pre participation portable echocardiograms done yearly over 3 years on 510 participants. Interpretable images: 92%

22% showed physiologic LV remodeling

Cardiac abnormalities found in 2.2% (protocol focus: HCM, DCM, MVP, PS, BiAV, aortic root, AS, AR, congenital coronary abnormalities, ARVD)

Avg time from set up to interpretation decreased from 17 minutes to 11 minutes

 I. Athletes heart- What could be normal?

II. Defined pathology- Should patient be allowed to participate?

HOCM

MVP

Different Sports
Maron, BJ. British Journal of Sports medicine 2009;43:649-656

Endurance (cycling, marathon, swimming) : Increase oxygen consumption, cardiac output, stroke volume and decrease in PVR. mod increase in BP. PRIMARILY volume load. Power (lifting, wrestling, javelin): mild inc CO and oxygen consumption, but marked increases in BP, PVR and HR. BPs reported up to 480/350mmHg. Inc wall thickness.

Primarily Pressure load

What is normal?

Pelliccia et al. The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes. NEJM 1991;324:295-301

Enlarged LVEDD
Pelliccia et al. The upper limit of physiologic cardiac hypertrophy in highly trained elite

athletes. NEJM 1991;324:295-301

Eccentric not concentric with smaller LVEDD

J Am Coll Cardiol. 2013;61(10):1027-1040. doi:10.1016/j.jacc.2012.08.1032

Differentiating between physiology and pathology

Figure Legend:
Differentiating Between Physiology and Pathology: Athlete's Heart Versus HCM and ARVC

Date of download: 3/28/2013

Copyright The American College of Cardiology. All rights reserved.

Race and gender effect

Basavarajaiah S et al. JACC 2008;51:2256-62 Papadakis M et al. EHJ 2011;32:2304-13

Black athletes have greater incidence of wall thickness >12mm (40%) vs Caucasian athletes (2-3%). Female athletes have less LV dilatation and LV wall thickness compared to male athletes even when adjusted for BSA.

Effect of detraining
Maron et al. BHJ 1993, Reduction in LV wall thickness after deconditioning in Olympic athletes. Pelliccia A, et al. Circulation 2002. Remodeling of LVH in elite athletes after long-term deconditioning.

Low EF
Abergel et al (JACC 2004): 286 Tour de France cyclists. LVDD >60mm and 12% with LVEF <52%. Abernathy et al (JACC 2003): 1282 NFL recruits screened with H+P/EKG, 156 had echo follow up. Low normal LVEF 50-60%, enlarged LV, but normal augmentation of systolic function with stress

Exercise echo to exclude cardiomyopathy

La Gerche, A. et al. J Am Coll Cardiol Img 2009;2:350-363

18 yo athlete with vasovagal syncope LVEF 50%

peak lateral e= 21 cm/s peak medial e= 10cm/s peak S velocity=10cm/s

Doppler indices of myocardial function

Increased Sm and Em in athletes compared to hypertensive and HCM patients. Vinereanu, AJC 2001;88:53-8; DAndrea, JASE 2003;16:154-161; Cardim, JASE 2003;16:223-32; Saghir, JASE 2007;20:151-7

Utility of CMR

courtesy S. Wolff

28 yo athlete with borderline dilated LV and LVEF 50% by echo

RV enlargement
Physiologic balanced and parallel RV and LV enlargement with training Especially in endurance athletes (soccer, track).

Confirmed in multiple CMR studies

Distinguish from ARVD
Scharag et al, JACC 2002; 40:1856 Scharf et al. AHJ 2010; 159:911-918 Hauser et al. AHJ 1985; 109: 1038

 Up to 24% elite athletes have LA >40mm in PSL view Increased afib incidence has also been reported in athletes, but not strongly related to LAE (many)

Left atrial enlargement

Pelliccia, et al. Circulation(2010), 122:698-706.

Aortic root dilatation in 2317 highly trained athletes

Aortic root >40mm (males) >34mm(females) uncommon and mandates close surveillance

More common cardiovascular pathologies and eligibility to participate in athletics

Case:
18 year old during pre-sports screening with murmur noted, follow up ECG.

BC#36
Athletes with probable or definitive clinical diagnosis of HCM should be precluded from most competitive sports, with possible exception of those of lowintensity regardless of phenotype or treatment/intervention. Athletes genotype (+), phenotype (-) with no cardiac symptoms or FH of SCD are not precluded, but are recommended to have frequent serial echo, EKG, Holter, exercise stress and CMR. Athletes with abnormal 12 lead ECG, with normal 2D echo, esp with FH(+) for HCM, should undergo CMR for regional LVH undetected by echo and delayed enhancement.

MVP

BC#36 recommendations Athletes with MVP and WITHOUT these features can compete in
all competitive sports
prior syncope due to arrhythmia sustained or repetitive and Nonsustained supraventricular and/or complex ventricular tachyarrhtyhmias on Holter severe MR LV EF <50% prior embolic event

family history of MVP-related sudden death

Athletes with MVP WITH any of above can compete in lowintensity competitive sports only

Summary
Pre-participation History/physical exam/+/-ECG (12point AHA guideline)
Echo findings of athletes heart-Eccentric/concentric hypertrophy, enlarged atria, RV enlargement, higher PA pressures, possibly LLN EF. Use of exercise echo/Doppler indices/CMR/detraining to differentiate between LVH and cardiomyopathy.

Follow aortic roots >4.0cm. Compare with first, not just prior year.
Bethesda Conference #36 recommendations

 Thank you

Cardiac physiology during exercise

Increase cardiac output primarily due to increased SV, not HR

?mechanism: early and rapid diastolic filling, increased diastolic volume, increased systolic contractility
Increase in PASP in athletes during intense exercise >non-athletes

Bicuspid aortic valve

BC#36 recommendations
(+)Bicuspid Aortic valve without aortic root dilatation and no sig AS/AR may participate in all competitive sports (+)BiAV with dilated aortic root 40-45mm can participate in low and mod static or low and mod dynamic competitive sports, but should avoid any sport with potential for bodily collision or trauma (+)BiAV and aortic root >45mm should participate in only low intensity competitive sport

Marfans criteria (2010 revised Ghent nosology)

(-) FH: any one Aortic criterion AND ectopia lentis Aortic criterion AND FBN1 mutation Aortic criterion AND systemic score >7

Ectopia lentis AND FBN1 mutation

(+) FH: Ectopia lentis Systemic score >7

24 year old with lens Aortic criterion (Z>/=2 above 20 years old , Z>/=3 below 20 years old, dislocation, (+)FH Marfans
or aortic dissection)

2.6cm 4.5cm

4.5cm at sinuses of Valsava= Z score of 4.25

Can he participate in sports?

Based on aortic root dimensions with close monitoring by echo q6 months can participate in low and mod competitive sports if following features absent: aortic root dilatation. transverse dimension >/=40mm, or Z score >2.0 mod to severe MR family history of aortic dissection or sudden death

Cost of ECG screening in US Halkin et al. JACC 2012. 60(22)

ECG screening in US would cost up to $69billion over 20 years and save 4,813 lives. Price per life saved $10million dollars. Not actual cost of tests. Vs.

Italian National Pre participation screening package cost per athlete is $60