Assessment of Left Ventricular Hypertrophy in a Trained Athlete: Differential Diagnosis of Physiologic Athlete's Heart From Pathologic Hypertrophy

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Abstract

Physiologic LV remodeling in young trained athletes as a consequence of chronic training can occasionally mimic certain pathologic conditions associated with sudden death, such as HCM. A small but important subset ofelite male athletes may show a borderline increased LV wall thickness of 13 to 15 mm, which defines a gray zone of overlap between the extreme expressions of athlete's heart and a mild HCM phenotype. Such diagnostic ambiguity can be resolved by using the paradigm of noninvasive parameters including testing with echocardiography (and, more recently, with CMR): left atrial and LV chamber dimensions and shape, brief periods of deconditioning to alter LV mass, measurement of oxygen consumption and diastolic filling, and recognition of familial occurrence of HCM or a pathogenic HCM-causing sarcomere mutation. Such distinctions between physiologic/benign athlete's heart and HCM, the most common cause of sudden death in the young in the United States, can be crucial. The recognition of HCM leads to disqualification from intense competitive sports to reduce sudden death risk and, when appropriate, permits initiation of therapeutic interventions.

Section snippets

Historical perspectives

The concept that the cardiovascular system of trained athletes differs structurally and functionally from that of untrained, normal individuals is remarkably more than 100 years old.1 Henschen1 is credited with the first description in 1899, using only a basic physical examination with careful percussion to recognize enlargement of the heart due to athletic activity in cross-country skiers. Henschen1 concluded that both dilatation and hypertrophy were present in trained athletes, involving the

Type of sport

Morphologic cardiac changes in athletes have been attributed primarily to the type of sport and, specifically, to the hemodynamic overload induced by various conditioning programs3, 4, 5, 6, 7, 8, 9 (Fig 1). Specifically, endurance sports (ie, cycling, cross-country skiing, and rowing) are associated with a predominant volume overload, whereas power disciplines (ie, weight and power lifting, shot put, and discus) are associated with a predominant pressure overload. In our experience, elite

Left ventricular remodeling

Responses of individual athletes to systematic conditioning are not uniform. Training induces some evidence of cardiac remodeling in about one half of trained athletes, consisting of alterations in ventricular chamber dimensions, namely, increased LV and right ventricular and left atrial cavity size (and volume), associated with normal systolic and diastolic function (Fig 3A-C). However, there is a considerable overlap in cardiac dimensions between a trained athlete population and age- and

Athlete's heart and cardiovascular disease

Because of the potentially adverse consequences of underlying cardiovascular disease in young athletes, considerable attention has focused on the clinical distinction of physiologically based athlete's heart from a variety of structural heart diseases.20, 21 This differential diagnosis has critical implications for dedicated athletes (and their physicians) because cardiovascular disease, namely, cardiomyopathies, may represent the basis for disqualification from competitive sports as a strategy

Statement of Conflict of Interest

All authors declare that there are no conflicts of interest.

Disclosure

Dr Barry J. Maron is a consultant for Gene Dx.

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