Left Ventricular Hypertrophy in Athletes: Differentiating Physiology From Pathology
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.
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.
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.
KeywordsAthlete’s heart Hypertrophic cardiomyopathy Left ventricular hypertrophy ECG Imaging
Body surface area
Global longitudinal strain
Late gadolinium enhancement
Left ventricular end diastolic diameter
Left ventricular hypertrophy
Left ventricular mass index
Left ventricular outflow tract
Relative wall thickness
Sudden cardiac death
T wave inversion
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
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- 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.•• 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.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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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