Prevalence of Modified ARVC Task Force Criteria in Elite Male Athletes
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1 ESC Congress Paris 2011 Prevalence of Modified ARVC Task Force Criteria in Elite Male Athletes A Zaidi, N Sheikh, S Gati, S Ghani, R Howes, S Sharma St George s, University of London, United Kingdom Conflict of interest: none declared
2 Athlete s Heart
3 Increased LV Dimensions in Athletes a. Pelliccia et al. NEJM 1991, b. Pelliccia et al. Ann Intern Med 1999
4 Athlete s Heart or HCM?
5 What about the Right Ventricle?
6 Healthy 23-year old non-athlete Healthy 23-year cyclist
7 Arrhythmogenic right ventricular cardiomyopathy (ARVC)
8 Causes of SCD in 118 UK Athletes Pathological Study De Noronha et al. Heart 2009
9 RV evaluation in athletes Diagnosis of ARVC Avoid unnecessary exclusion Importance of echocardiography
10 LV RV Hauser Am Heart J 1985 N = 12 Henriksen EHJ 1999 N = 42 D Andrea Echocardiography 2003 N = 58 Kasikcioglu Heart Vessels 2005 N = 52 Scharhag Int J Sports Medicine N = 23 Complex Geometry Paucity of Athlete Data Multiple Measures Athlete s RV Echo challenges Reference Values from non-athletic cohorts N = 41
11 1. Imaging (echo, cmri, angiography) 2. Histology 3. ECG (Repolarisation) 4. ECG (Depolarisation) 5. Arrhythmias 6. Family history Diagnostic Probability Definite Borderline Possible Criteria 2 major 1 major + 2 minor 4 minor 1 major + 1 minor 3 minor 1 major 2 minor Marcus et al. Circulation 2010
12 ARVC Task Force Criteria Minor (mm/m 2 ) Major (mm/m 2 ) Regional RV akinesia, dyskinesia or aneurysm RVOT Plax (mm/m 2 ) 16 (87%) 19 (95%) Specificity for ARVC RVOT1 (mm/m 2 ) 18 (80%) 21 (95%) Marcus et al. Circulation 2010
13 Objectives 1. To assess prevalence of echocardiographic ARVC TFC in healthy male, elite athletes (EA) 2. To assess factors associated with +ve TFC in athletes:? LV dimensions.? Training intensity.
14 Methods 200 male elite athletes (A) + 50 controls (C) Symptom hx and family hx Exercise intensity noted (hrs/week) 12-lead ECG Transthoracic echo: PLAX RVOT and PSAX RVOT1 (indexed to BSA) RV akinesia, dyskinesia or aneurysm LVEDD / BSA
15 RV Echo Measurements RVOT Plax RVOT1 D
16 Exclusion Criteria Relevant symptoms (e.g. exertional CP or syncope) Clear evidence of other cardiac pathology Definite family history of cardiomyopathy
17 Results
18 Background Data Controls (C) Athletes (A) P-value (A vs C) n Mean Age (years) NS Mean Exercise (hours/week) P <
19 Athlete Demographics Cricket Football Diving Swimming Rowing Tennis Hockey Squash Running Basketball Speed skating Figure skating Cycling Taekwondo Rugby Sailing Gymnastics Athletics
20 RV Dimensions Athletes vs Controls P < P =
21 Variability Variability (% of mean) Intra-observer Inter-observer RVOT Plax RVOT
22 RV Dimensions Compared to TFC RVOT Plax (mm/m 2 ) RVOT1 (mm/m 2 ) Minor Major No akinesia, dyskinesia or aneurysm seen
23 RV Enlargement - Associations NS P < P =
24 LV/RV Ratio NS NS
25 Conclusions RV dimensions Are increased in male athletes (vs controls). Often exceed TFC dimensions Must be interpreted in conjunction with nondimensional echo criteria (Comparison with ARVC cases) Symmetrical remodelling RV dimensions associated with training intensity.
26 Conclusions Echo components of TFC use with caution in athletes! Interpret echo RV dimensions in the context of History Family history ECG Gender LV dimensions Presence of RWMA Training intensity
27 Questions?
28 ESC Congress Paris 2011 Prevalence of modified ARVC Task Force Criteria in elite male athletes STA Zaidi, N Sheikh, S Gati, S Ghani, R Howes, S Sharma St George s, University of London, United Kingdom
29 n = 650 Mean RVOT1 (mm) D Andrea et al 31.3 (M + F) Our data 31.7 (M)
30 ECG and Echo Anomalies Athletes vs ARVC Athletes (%) ARVC (%) P-value (A vs ARVC) Right praecordial delay Q waves < Epsilon wave RVH Anterior TWI < Inferior TWI L-axis R-axis RSR prbbb RBBB Akinetic segments < Dyskinesia / aneurysm <0.0001
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