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Left Ventricular Hypertrophy in Athletes: Differentiating Physiology From Pathology

  • Daniel X. AugustineEmail author
  • Liz Howard
Sports Cardiology (M Papadakis, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Sports Cardiology

Abstract

Purpose of review

The changes that occur in athlete’s heart are influenced by a number of factors including age, gender, ethnicity and the type of cardiovascular training. It is therefore important that the clinician is able to integrate all of these factors when assessing athletes to be able to guide investigations appropriately and to distinguish pathology from physiology. This review discusses the potential diagnostic conundrums when trying to differentiate physiological left ventricular hypertrophy from pathological hypertrophic cardiomyopathy in athletes. The mechanism of physiological and pathological hypertrophy is discussed together with history, clinical and investigational findings that can help to identify pathology.

Recent findings

Athletes with hypertrophic cardiomyopathy are more likely to have non-concentric left ventricular hypertrophy (LVH), an elevated relative wall thickness, lateral ECG changes and a smaller LV cavity than athletes with physiological LVH. Certain diastolic echocardiographic parameters when used as part of an algorithm (e′; E/E′; E/A) can help to distinguish physiology from pathology, and there is evidence that assessment of global longitudinal strain during exercise echocardiography may be of use in the future. Cardiac MRI is an important imaging modality that can have an additive effect over echocardiography in the diagnosis of cardiomyopathy. Late gadolinium enhancement is a recognised advantage for cardiac magnetic resonance to allow detection of fibrosis in hypertrophic cardiomyopathy. T1 mapping and extracellular volume quantification may be a tool for the future to help distinguish athlete’s heart from HCM.

Summary

Cardiac adaptation to exercise and training in athletes, the athlete’s heart causes electrophysiological and geometric changes that may mimic mild phenotypes of a pathological cardiomyopathy. This review article summarises a systematic approach to the assessment of left ventricular hypertrophy in athletes and describes pertinent clinical and investigation findings that can help to differentiate physiology from pathology.

Keywords

Athlete’s heart Hypertrophic cardiomyopathy Left ventricular hypertrophy ECG Imaging 

Abbreviations

AH

Athlete’s heart

BSA

Body surface area

ECG

Electrocardiogram

ECV

Extracellular volume

EF

Ejection fraction

GLS

Global longitudinal strain

HCM

Hypertrophic cardiomyopathy

LGE

Late gadolinium enhancement

LV

Left ventricle

LVEDd

Left ventricular end diastolic diameter

LVH

Left ventricular hypertrophy

LVMI

Left ventricular mass index

LVOT

Left ventricular outflow tract

RWT

Relative wall thickness

SCD

Sudden cardiac death

TWI

T wave inversion

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Finocchiaro G, Dhutia H, D’Silva A, Malhotra A, Steriotis A, Millar L, et al. Effect of sex and sporting discipline on LV adaptation to exercise. JACC Cardiovasc Imaging. 2017;10(9):965–72.CrossRefGoogle Scholar
  2. 2.
    Papadakis M, Wilson MG, Ghani S, Kervio G, Carre F, Sharma S. Impact of ethnicity upon cardiovascular adaptation in competitive athletes: relevance to preparticipation screening. Br J Sports Med. 2012;46(Suppl 1):i22–8.CrossRefGoogle Scholar
  3. 3.
    Pelliccia A, Culasso F, Di Paolo FM, Maron BJ. Physiologic left ventricular cavity dilatation in elite athletes. Ann Intern Med. 1999;130(1):23–31.CrossRefGoogle Scholar
  4. 4.
    Sheikh N, Papadakis M, Carre F, Kervio G, Panoulas VF, Ghani S, et al. Cardiac adaptation to exercise in adolescent athletes of African ethnicity: an emergent elite athletic population. Br J Sports Med. 2013;47(9):585–92.CrossRefGoogle Scholar
  5. 5.
    Sheikh N, Sharma S. Impact of ethnicity on cardiac adaptation to exercise. Nat Rev Cardiol. 2014;11(4):198–217.CrossRefGoogle Scholar
  6. 6.
    Corrado D, Basso C, Rizzoli G, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol. 2003;42(11):1959–63.CrossRefGoogle Scholar
  7. 7.
    Authors/Task Force members, Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, et al. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(39):2733–79.CrossRefGoogle Scholar
  8. 8.
    •• Sharma S, Drezner JA, Baggish A, Papadakis M, Wilson MG, Prutkin JM, et al. International recommendations for electrocardiographic interpretation in athletes. J Am Coll Cardiol. 2017 Feb 28;69(8):1057-1075. Consensus statement on the interpretation of athletes ECG identifying physiological changes and changes that may be associated with pathologyGoogle Scholar
  9. 9.
    Papadakis M, Carre F, Kervio G, Rawlins J, Panoulas VF, Chandra N, et al. The prevalence, distribution, and clinical outcomes of electrocardiographic repolarization patterns in male athletes of African/Afro-Caribbean origin. Eur Heart J. 2011 Oxford University Press;32(18):2304–13.CrossRefGoogle Scholar
  10. 10.
    Papadakis M, Wilson MG, Ghani S, Kervio G, Carre F, Sharma S. Impact of ethnicity upon cardiovascular adaptation in competitive athletes: relevance to preparticipation screening. Br J Sports Med. 2012;46:i22–8.CrossRefGoogle Scholar
  11. 11.
    Malhotra A, Dhutia H, Gati S, Yeo T, Dores H, Bastiaenen R, et al. Anterior T-wave inversion in young white athletes and nonathletes. J Am Coll Cardiol. 2017;69(1):1.CrossRefGoogle Scholar
  12. 12.
    Schnell F, Riding N, O’Hanlon R, Axel Lentz P, Donal E, Kervio G, et al. Recognition and significance of pathological T-wave inversions in athletes. Circulation. 2015;131(2):165–73.CrossRefGoogle Scholar
  13. 13.
    Sheikh N, Papadakis M, Wilson M, Malhotra A, Adamuz C, Homfray T, et al. Diagnostic Yield of Genetic Testing in Young Athletes with T-wave Inversion. Circulation. 2018 May;138:1184–1194.CrossRefGoogle Scholar
  14. 14.
    Foale R, Nihoyannopoulos P, McKenna W, Kleinebenne A, Nadazdin A, Rowland E, et al. Echocardiographic measurement of the normal adult right ventricle. Br Heart J. 1986;56(1):33–44.CrossRefGoogle Scholar
  15. 15.
    Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2016;18(12):1440–63.CrossRefGoogle Scholar
  16. 16.
    Morganroth J, Maron BJ, Henry WL, Epstein SE. Comparative left ventricular dimensions in trained athletes. Ann Intern Med. 1975;82(4):521–4.CrossRefGoogle Scholar
  17. 17.
    Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015 Oxford University Press;16(3):233–271.CrossRefGoogle Scholar
  18. 18.
    Echocardiographic normal ranges meta-analysis of the left heart (EchoNoRMAL) Collaboration. The Ethnic-specific normative reference values for echocardiographic LA and LV size, LV mass, and systolic function: the EchoNoRMAL study. JACC Cardiovasc Imaging. 2015;8(6):656–65.CrossRefGoogle Scholar
  19. 19.
    Grossman W, Jones D, McLaurin LP. Wall stress and patterns of hypertrophy in the human left ventricle. J Clin Invest. 1975;56(1):56–64.CrossRefGoogle Scholar
  20. 20.
    Spence AL, Naylor LH, Carter HH, Buck CL, Dembo L, Murray CP, et al. A prospective randomised longitudinal MRI study of left ventricular adaptation to endurance and resistance exercise training in humans. J Physiol (22):5443-52.CrossRefGoogle Scholar
  21. 21.
    Riding NR, Sharma S, McClean G, Adamuz C, Watt V, Wilson MG. Impact of geographical origin upon the electrical and structural manifestations of the black athlete’s heart. Eur Heart J. 2018:ehy521–ehy521.Google Scholar
  22. 22.
    Katz AM. Cardiomyopathy of overload. N Engl J Med. 1990;322(2):100–10.CrossRefGoogle Scholar
  23. 23.
    Pluim BM, Zwinderman AH, van der Laarse A, van der Wall EE. The athlete’s heart. Circulation. 2000 Lippincott Williams & Wilkins;101(3):336–44.Google Scholar
  24. 24.
    Basavarajaiah S, Wilson M, Whyte G, Shah A, McKenna W, Sharma S. Prevalence of hypertrophic cardiomyopathy in highly trained athletes: relevance to pre-participation screening. J Am Coll Cardiol. 2008;51(10):1033–9.CrossRefGoogle Scholar
  25. 25.
    Spirito P, Pelliccia A, Proschan MA, Granata M, Spataro A, Bellone P, et al. Morphology of the “athlete’s heart” assessed by echocardiography in 947 elite athletes representing 27 sports. Am J Cardiol. 1994;74(8):802–6.CrossRefGoogle Scholar
  26. 26.
    Pelliccia A, Maron BJ, Culasso F, Spataro A, Caselli G. Athlete’s heart in women: echocardiographic characterization of highly trained elite female athletes. JAMA. 1996;276(3):211–5.CrossRefGoogle Scholar
  27. 27.
    Rawlins J, Carre F, Kervio G, Papadakis M, Chandra N, Edwards C, et al. Ethnic differences in physiological cardiac adaptation to intense physical exercise in highly trained female athletes. Circulation. 2010;121(9):1078–85.CrossRefGoogle Scholar
  28. 28.
    Basavarajaiah S, Boraita A, Whyte G, Wilson M, Carby L, Shah A, et al. Ethnic differences in left ventricular remodeling in highly-trained athletes: relevance to differentiating physiologic left ventricular hypertrophy from hypertrophic cardiomyopathy. J Am Coll Cardiol. 2008;51(23):2256–62.CrossRefGoogle Scholar
  29. 29.
    Papadakis M, Wilson MG, Ghani S, Kervio G, Carre F, Sharma S. Impact of ethnicity upon cardiovascular adaptation in competitive athletes: relevance to preparticipation screening. Br J Sports Med. 2012;46:i22–8.CrossRefGoogle Scholar
  30. 30.
    Sharma S, Maron BJ, Whyte G, Firoozi S, Elliott PM, McKenna WJ. Physiologic limits of left ventricular hypertrophy in elite junior athletes: relevance to differential diagnosis of athlete’s heart and hypertrophic cardiomyopathy. J Am Coll Cardiol. 2002;40(8):1431–6.CrossRefGoogle Scholar
  31. 31.
    Sheikh N, Papadakis M, Carre F, Kervio G, Panoulas VF, Ghani S, et al. Cardiac adaptation to exercise in adolescent athletes of African ethnicity: an emergent elite athletic population Br J Sports Med 2013;47:585-592CrossRefGoogle Scholar
  32. 32.
    Sheikh N, Papadakis M, Schnell F, Panoulas V, Malhotra A, Wilson M, et al. Clinical profile of athletes with hypertrophic cardiomyopathy. Circ: Cardiovasc Imaging. 2015;8(7):e003454.Google Scholar
  33. 33.
    Caselli S, Maron MS, Urbano-Moral J, Pandian NG, Maron BJ, Pelliccia A. Differentiating Left Ventricular Hypertrophy in Athletes from That in Patients With Hypertrophic Cardiomyopathy. Am J Cardiol. 2014 Nov 1;114(9):1383-9.CrossRefGoogle Scholar
  34. 34.
    • Finocchiaro G, Dhutia H, D’Silva A, Malhotra A, Sheikh N, Narain R, et al. Role of Doppler diastolic parameters in differentiating physiological left ventricular hypertrophy from hypertrophic cardiomyopathy. J Am Soc Echocardiogr. 2018;31(5):606–613.e1 Comprehensive paper summarizing diastolic echo parameters and algorithm that may help to distinguish physiological LVH from HCM.CrossRefGoogle Scholar
  35. 35.
    Schnell F, Matelot D, Daudin M, Kervio G, Mabo P, Carré F, et al. Mechanical dispersion by strain echocardiography: a novel tool to diagnose hypertrophic cardiomyopathy in athletes. J Am Soc Echocardiogr. 2017;30(3):251–61.CrossRefGoogle Scholar
  36. 36.
    Maron MS, Maron BJ, Harrigan C, Buros J, Gibson CM, Olivotto I, et al. Hypertrophic cardiomyopathy phenotype revisited after 50 years with cardiovascular magnetic resonance. J Am Coll Cardiol. 2009;54(3):220–8.CrossRefGoogle Scholar
  37. 37.
    McDiarmid AK, Swoboda PP, Erhayiem B, Lancaster RE, Lyall GK, Broadbent DA, et al. Athletic Cardiac Adaptation in Males Is a Consequence of Elevated Myocyte Mass. Circ Cardiovasc Imaging.2016 Apr;9(4):e003579.Google Scholar
  38. 38.
    Wilson M, O’Hanlon R, Prasad S, Deighan A, MacMillan P, Oxborough D, et al. Diverse patterns of myocardial fibrosis in lifelong, veteran endurance athletes. J Appl Physiol. 2011;110(6):1622–6.CrossRefGoogle Scholar
  39. 39.
    Graham-Brown M, McCann GP. T1 Mapping in Athletes: A Novel Tool to Differentiate Physioloical Adaptation From Pathology. Circ Cardiovasc Imaging 2016 Apr;9(4):e004706..Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Royal United Hospital Bath NHS Foundation TrustBathUK
  2. 2.Cardiology Clinical Academic GroupSt George’s, University of LondonLondonUK

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