Differentiating Left Ventricular Hypertrophy in Athletes from That in Patients With Hypertrophic Cardiomyopathy

doi:10.1016/j.amjcard.2014.07.070

The American Journal of Cardiology

Volume 114, Issue 9, 1 November 2014, Pages 1383-1389

https://doi.org/10.1016/j.amjcard.2014.07.070 Get rights and content

Highlights

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We studied athletes and patients with HC with borderline LV hypertrophy (13 to 15 mm).
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Clinical and echocardiographic parameters were compared.
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LV cavity <54 mm distinguished HC from athlete's heart with the highest sensitivity and specificity.
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Athletes were characterized by larger left atria compared with patients with HC.
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Also, diastolic functional parameters, electrocardiography, and family history proved useful in the differential diagnosis.

Identification of hypertrophic cardiomyopathy (HC) in young athletes is challenging when left ventricular (LV) wall thickness is between 13 and 15 mm. The aim of this study was to revise the ability of simple echocardiographic and clinical variables for the differential diagnosis of HC versus athlete's heart. Twenty-eight athletes free of cardiovascular disease were compared with 25 untrained patients with HC, matched for LV wall thickness (13 to 15 mm), age, and gender. Clinical, electrocardiographic, and echocardiographic variables were compared. Athletes had larger LV cavities (60 ± 3 vs 45 ± 5 mm, p <0.001), aortic roots (34 ± 3 vs 30 ± 3 mm, p <0.001), and left atria (42 ± 4 vs 33 ± 5 mm, p <0.001) than patients with HC. LV cavity <54 mm distinguished HC from athlete's heart with the highest sensitivity and specificity (both 100%, p <0.001). Left atrium >40 mm excluded HC with sensitivity of 92% and specificity of 71% (p <0.001). Athletes showed higher e′ velocity by tissue Doppler imaging than patients with HC (12.5 ± 1.9 vs 9.3 ± 2.3 cm/second, p <0.001), with values <11.5 cm/second yielding sensitivity of 81% and specificity of 61% for the diagnosis of HC (p <0.001). Absence of diffuse T-wave inversion on electrocardiography (specificity 92%) and negative family history for HC (specificity 100%) also proved useful for excluding HC. In conclusion, in athletes with LV hypertrophy in the “gray zone” with HC, LV cavity size appears the most reliable criterion to help in diagnosis, with a cut-off value of <54 mm useful for differentiation from athlete's heart. Other criteria, including LV diastolic dysfunction, absence of T-wave inversion on electrocardiography, and negative family history, further aid in the differential diagnosis.

Section snippets

Methods

From January 2008 to June 2009, 1,191 consecutive highly trained athletes were evaluated at the Institute of Sport Medicine and Science in Rome, as potential participants in the 2008 Beijing Olympic Games and/or the 2009 Pescara Pan-Mediterranean Games. Of these, 28 athletes (2.3%) were selected for the present study, on the basis of age 18 to 40 years and the echocardiographic finding of absolute LV wall thickness of 13 to 15 mm, which has been defined as the gray zone of overlap of

Results

Comparative echocardiographic and Doppler LV findings in athletes and patients with HC are listed in Table 1. The distribution of LV hypertrophy was different in the 2 groups, in that anterior ventricular septum was thicker in patients with HC compared with athletes, whereas the posterior ventricular septum, posterior free wall, and anterolateral wall were thicker in athletes.

The LV cavity (end-diastolic and end-systolic) was substantially larger in athletes compared with patients with HC;

Discussion

Diagnosis of HC in young competitive athletes may be challenging when the extent of LV hypertrophy is mild, falling into the so-called gray zone of uncertainty between physiologic LV remodeling and mild phenotypic expression of the disease.8, 9, 10, 11, 18 This differential diagnosis is a not uncommon clinical dilemma, and it is relevant because of the therapeutic and social implications that HC diagnosis conveys, with the potential for disqualification from organized sports activities.3, 4, 5,

Disclosures

The authors have no conflicts of interest to disclose.

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Athlete’s heart is characterized by cardiac remodeling features that can resemble those found in pathological conditions. Distinguishing athletic cardiac remodeling from cardiomyopathy is a frequent medical dilemma for physicians evaluating an athlete; there are in fact several “gray zones” in which physiology and pathology overlap and therefore it is essential to relate the degree of cardio-circulatory adaptations of athletes to the biomechanical characteristics of the practiced sport. It is therefore necessary to have a precise definition of the features of the athlete’s heart and stringent criteria to optimize the clinical management of these subjects, in order to be able to make a differential diagnosis with hypertrophic cardiomyopathy, dilated cardiomyopathy, left ventricular noncompaction, and arrhythmogenic cardiomyopathy.
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View all citing articles on Scopus

: This study was funded by the Italian National Olympic Committee.

: See page 1388 for disclosure information.

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CardiomyopathyDifferentiating Left Ventricular Hypertrophy in Athletes from That in Patients With Hypertrophic Cardiomyopathy

Highlights

Section snippets

Methods

Results

Discussion

Disclosures

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes

N Engl J Med

Screening for hypertrophic cardiomyopathy in young athletes

N Engl J Med

Sudden death in young athletes

N Engl J Med

Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006

Circulation

36th Bethesda Conference: eligibility recommendations for competitive athletes with cardiovascular abnormalities

J Am Coll Cardiol

Recommendations for competitive sports participation in athletes with cardiovascular disease

Eur Heart J

Cardiomyopathy
Differentiating Left Ventricular Hypertrophy in Athletes from That in Patients With Hypertrophic Cardiomyopathy