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 1
The Athlete in CV Medicine Where do they come from and Why? The Athlete Sudden Death Asymptomatic Symptomatic Athlete s Heart Vs. Pathology Syncope Arrhythmias ASHD HTN Stamina Athlete s Heart: Care of the Athlete The Athlete Asymptomatic or Symptomatic Athlete s Heart Vs. Pathology Pre-participation screening Insurance physicals Well checks Pre-operative assessment Risk factors assessment visits Cardiac Remodeling: Health vs. Disease Hemodynamic Stress of Sport Pathophysiology of Disease 2
Cardiac Remodeling: Physiology Classic concept of LV remodeling Aortic Regurgitation Aortic Stenosis Volume Challenge Pressure Challenge Cardiac Remodeling: Physiology Endurance Activities Strength Activities Sustained CO 4 to 5 times rest HR & SV Vasodilation Volume Challenge 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 Eccentric LVH RV Dilation Concentric LVH Familial DCM Idiopathic DCM Toxic DCM Valvular Heart Disease ARVC Exercise RVC (?) HCM Hypertensive CMP Non-compaction Infiltrative CMP 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 : 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 Am J Physiol. 2008 BMJ 2012 Uncertainty #1: LV Chamber Enlargement vs. Pathologic 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 6
Uncertainty #2: RV Chamber Enlargement : 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 7
Uncertainty #2: RV Chamber Enlargement Uncertainty #2: RV Chamber Enlargement Whyte et al. JAP 2011 Exercise- Induced CMP??? LaGerche et al. EHJ 2011 Uncertainty #2: RV Chamber Enlargement vs. Pathologic 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? 8
Uncertainty #3: Thick LV Walls : Least frequent but most problematic issue Expected with strength (isometric) training Mild symmetric concentric LVH Accompanied by no changes south of the mitral valve Myocardial Thickening Accompanied by normal to hyperdynamic resting LVEF (>60%) Marked regional thickening not physiologic until proven otherwise! Uncertainty #3: Thick LV Walls Adult Athletes Junior Athletes Pellicia et al NEJM 1991 Sharma et al JACC 2002 Uncertainty #3: Thick LV Walls Not a single healthy college athlete with walls > 14 Weiner et al. JASE 2012 9
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 vs. Pathologic 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 Eccentric LVH RV Dilation Concentric LVH Familial DCM Idiopathic DCM Toxic DCM Valvular Heart Disease ARVC Exercise RVC (?) HCM Hypertensive CMP Non-compaction Infiltrative CMP 10
Thank You! 11