Cardiac hypertrophy : differentiating disease from athlete
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1 Cardiac hypertrophy : differentiating disease from athlete Ario Soeryo Kuncoro, MD, Cardiologist Echocardiography Division, National Cardiovascular Centre Harapan Kita-Jakarta Departement of Cardiology and Vascular Medicine, University of Indonesia
2 Introduction Left ventricle hypertrophy could be physiological or pathological Hypertrophy is defined as LV mass exceeding normal values Hypertrophy can occur due to intense training called athlete s heart pathological hypertrophy could be caused by hypertension, cardiomypathies, aortic stenosis, infiltrative disease
3 When do you call it hypertrophy? Marwick et al. J Am Soc Echocardiogr 2015:28
4 Sudden cardiac death in athlete sudden death of young competitive athlete is an important public health problem sudden death were predominantly caused by cardiovascular disease (56%) Prepartipation screening before enrollment is somewhat complex
5 Cardiovascular Causes of sudden death in young athlete (US National Registry 1866 athletes) HCM HCM other WPW dilated CM AS aortic rupture CAD LAD bridge MVP ion channel ARVC Myocarditis possible HCM coronary anomalies
6 Strategy to differentiate Cardiomyopathy or athlete s heart Applied when there is NO sign for SAM under resting condition 2 1 SAM is strongly suggest HCM 4 3 Maron et al. Circulation 1995:91
7 1. Patterns of LVH in athlete 28 studies, more than 1000 athletes ventricular septal to free wall thickness ratio (M mode) within normal limits in athlete :<1.3 Mild asymmetric thickening of anterior basal septum (13-15 mm) Maron. J Am Coll Cardiol 1986;7
8 1. Patterns of LVH in athlete male female
9 Patterns of LVH in Cardiomyopathy In HCM group: 20% with LVwall thickness above highest value 6% HCM with symmetrical LVH Healthy subject also has asymmetrical LVH Petersen et al.journal of Cardiovascular Magnetic Resonance 2005:7
10 Mild HCM and athlete Circ Cardiovasc Imaging 20
11 2. Dimension changes : heart remodeling regular trainers will cause the heart to enlarge combination of cavity enlargement (dilatation) and increased wall thickness type of exercise as will give different impact to the heart Isometric training stimulates hypertrophy with normal cavity (concentric) Aerobic stimulates hypertrophy and cavity dilatation (eccentric) athletes with combination type of training will blurred the distinction
12 Comparison of 28 elite athlete to 25 HC LV dimension is the most reliable parameter to distinguish HCM cut off <54 mm Caselli et al. Am J Cardiol 2014;114
13 Dimension changes depends on different type of sports cycling rowing swimming x country skiing L.D.running soccer tennis hockey alpine skiing fencing volley ball weight-lifting wrestling equestrian yachting LV size LV wall thickness Impact to LV dimensions (%)
14 Dimension changes: in various types of sports Pluim et al. Circulation 1999;100
15 Dimension changes : atrial size Cut off value is <40 mm (2D measurement) Caselli et al. Am J Cardiol 2014;114
16 Parameters to distinguish athlete to HCM Caselli et al. Am J Cardiol 2014;114
17 Distinguishing physiological LVH from pathological LVH in athletes with mild Concentric HCM Sensitivity Specificity p value LVEDD<51 mm <0.001 LVEDD<54mm avge/e;> Avg E/e > relative wall thickness > LA <38 mm LA<40mm Lat e <0.11 m/s Lat e <0.09 m/s Septal e <0.11m/s <0.001 Septal e <0.09m/s mitral A > <0.001 mitral A > Sheikh et alcirc Cardiovasc Imaging 2015;8
18 3. LV filling in athlete 15 healthy subjects vs 15 runners (12 miles/ wk for 6 mths) echo parameters for diastolic filling : Doppler : peak E, peak A, M mode ( Q-D, Q-Efv) JACC 1996;8:289-93
19 Nagueh et al. J Am Soc Echocardiogr 2009:22 Nagueh et al. J Am Soc Echocardiogr 2016;29
20 4. Effects of (training and ) detraining cessation 1 week >2 weeks LVEDD 8% LV mass 15% 25% posterior wall thickness 27% 38% Ehsani et al. Am J Cardiol 1978;42
21 max LV wall thickness 13.8 mm ( trained) 10.5 mm (detrained) > change of 5-33% Maron. Br Heart J 1993;69
22 Tissue Doppler Imaging in athlete Pulse Doppler Tissue athlete HCM Notes e > < s >9cm/s <9 cm/s 11.5cm/s raise suspicion for pathological LVH1 EF can be normal or high depends on the stage E/e low increased e /a normal <1 related to NYHA and exercise capacity 25% detected in HCM and hypertensive pts2 Br Heart J 1992:68 Soc Echocardiogr 2003;16
23 et al.j Am Soc Echocardiogr 2007; 20 Myocardial strain in athlete: differentiate from diseased heart 90% of subjects athlete had: GLS <21% e /a >1 e > 16 cm/s s >10cm/s compare to Hypertensive subjects
24 LV volume parameters : LVEF, LVEDVI,LVESVI,LVSVI,LV masss Index Geometric indices (diastolic wall thickness, wall thickness ratio, diastolic wall-to-volume ratio,systolic
25 Summary Distinguishing normal left ventricular hypertrophy from abnormal hyperrophy can be problematic Multimodality imaging can be helpful to detect abnormal hypertrophy Physiological changes in athlete overlap with mild Hypertrophic cardiomyopathy Echocardiography can help detect structural and functional changes in athlete
26
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