Use of Multimodality Cardiovascular Imaging in Young Adult Competitive Athletes

Publication Date: May 1, 2020
Last Updated: March 14, 2022

Key Points

EXERCISE-INDUCED CARDIAC REMODELING (EICR)

  1. Clinical imaging specialists performing and/or interpreting imaging studies in CA should possess a basic knowledge of fundamental exercise physiology and EICR.
  2. The magnitude (i.e., absolute wall thickness and chamber dimensions/volumes) and geometry (eccentric vs. concentric) of LV adaptation in CA is defined by the complex interplay between numerous factors, including sport type, sex, ethnicity, and duration of prior exercise exposure.
  3. When due to EICR, RV dilation, a common adaptation in CA engaging in endurance sports, should be accompanied by LV eccentric remodeling/hypertrophy and biatrial dilation.
  4. Mild aortic sinus or ascending aortic dilation may occur in young CA but absolute aortic measurements of ≥40 mm (men) and ≥34 mm (women) are uncommon. A finding of aortic sinus or ascending aortic dimensions in excess of these sex-specific cut-points should prompt clinical consideration of aortic pathology and subsequent imaging with either gated CTA or CMR.

DIFFERENTIATING EICR FROM PATHOLOGY

Left Ventricular Wall Thickening

  1. LV wall thickening attributable to EICR is typically mild, with values in the range of 11–13 mm in Caucasian CA, and up to 15 mm in Black CA and Caucasian CAwith large body habitus. Values in excess of these cut-points should raise suspicion of pathologic LV remodeling.
  2. TTE measurements of wall thickness taken from parasternal long-axis views must be made carefully to avoid inclusion of RV septal trabeculations and posterolateral chordal tissue.
  3. LV wall thickening with concomitant reductions in pulsedwave Doppler and/or tissue Doppler indices of diastolic function and/or reductions in LV longitudinal systolic strain should raise suspicion of pathologic LV remodeling.
  4. LV wall thickening of unclear etiology or incomplete visualization of all LV wall segments during TTE should prompt additional imaging with CMR.

Left Ventricular Dilation

  1. Initial characterization of LV chamber volume should be performed using TTE. Among CA with suspected pathologic dilation, CMR should be performed to confirm dilation and to characterize structure and function of the LV and other chambers.
  2. The magnitude of LV and LA dilation in CA cannot be used in isolation to differentiate EICR from pathology. Integration of clinical history, myocardial function, and additional diagnostic testing are generally required for this purpose.
  3. Low normal to mildly reduced (45–55%) LV ejection fractions in asymptomatic CA with LV dilation are common and can be considered physiologic when accompanied by normal indices of diastolic function and concomitant dilation of the RV and both atria.

Right Ventricular Dilation

  1. RV dilation, in conjunction with LV dilation, is common among endurance-trained CA. Physiologic dilation of the RV should occur without structural (i.e. aneurysms and/or focal wall thinning) or functional (i.e. focal hypokinesis) RV abnormalities. Clinical cut-points for RV dilation cannot be used in isolation to differentiate EICR from pathologic RV remodeling.
  2. TTE has important limitations with respect to delineating the magnitude and etiology of RV dilation in CA. CMR should be performed in all CA with RV dilation of unclear etiology.

Hypertrabeculation

  1. Physiologic hypertrabeculation of the LV apex is common among symptomatic CA. Most frequently observed in Black and endurance-sport CA, physiologic hypertrabeculation should be accompanied by normal LV wall thickness and normal indices of LV systolic and diastolic function.
  2. TTE, often requiring the addition of an IV ultrasound enhancing agent for image optimization, represents first line imaging for characterization LV hypertrabeculation among CA. Incomplete characterization by TTE of the LV apex among CA with suspected noncompaction cardiomyopathy should prompt CMR imaging.

PRE-PARTICIPATION CARDIOVASCULAR SCREENING

  1. Routine PPCS of young CA should include a focused personal and medical history and physical examination. The addition of a 12-lead ECG may be considered in situations with adequate financial resources and clinical expertise.
  2. The use of noninvasive imaging including comprehensive and limited TTE, CTA, and CMR is not recommended as a first-line strategy during PPCS.
  3. PPCS programs should ensure timely access to clinical centers with sports cardiology and clinical imaging expertise to facilitate the comprehensive multimodality imaging required to evaluate findings detected during PPCS.

THE SYMPTOMATIC COMPETITIVE ATHLETE

Exertional Chest Discomfort

  1. TTE should be performed as the initial noninvasive imaging test in CA presenting with possible or probable cardiac chest pain.
  2. CA presenting with possible or probable cardiac chest pain should undergo maximal effort-limited exercise testing with or without adjunctive imaging as dictated by current guidelines. Exercise stress echocardiography with immediate postexercise imaging should be applied with caution as rapid heart rate recovery in CA often renders imaging non-diagnostic for the evaluation of ischemia.
  3. TTE imaging in CA with possible or probable cardiac chest pain should include careful and definitive delineation of both the left and right coronary origins and proximal course to exclude anomalous coronary circulation. Failure of TTE to confirm normal coronary anatomy requires additional imaging with CMR or gated CTA as dictated by patient, provider, and institutional preferences.

Syncope

  1. Neurally-mediated syncope in the post-exercise period or in situations unrelated to exercise is common among CA and does not require evaluation with any noninvasive imaging modality.
  2. CA presenting with syncope of unclear etiology, particularly syncope during exercise, should undergo comprehensive multimodality imaging beginning with TTE and extending, on a case-by-case basis, to CTA or CMR to exclude structural and valvular heart disease as part of a comprehensive evaluation.
  3. CA presenting with syncope of unclear etiology should undergo maximal effort-limited exercise testing with or without adjunctive imaging as dictated by current guidelines.

Palpitations and Arrhythmias

  1. CA presenting with palpitations or subjective arrhythmias that occur or intensify during exercise should undergo TTE to diagnose or exclude underlying structural disease. Additional imaging with CMR may be appropriate on a case-by-case basis.
  2. CA presenting with palpitations or subjective arrhythmias that occur or intensify during exercise should undergo maximal effort-limited exercise testing with or without adjunctive imaging as dictated by current guidelines.
  3. All CA undergoing evaluation for ventricular pre-excitation, both asymptomatic and symptomatic, should undergo TTE to exclude concomitant Ebstein’s anomaly, PRKAG2 gene-mediated hypertrophic cardiomyopathy, and complex forms of congenital heart disease.

Inappropriate Exertional Dyspnea

  1. Inappropriate exertional dyspnea may occur in the context of numerous cardiovascular diseases. Comprehensive TTE should be performed in CA presenting with inappropriate exertional dyspnea, and in CA with a previously diagnosed noncardiac cause of inappropriate exertional dyspnea who do not demonstrate adequate response to therapy.
  2. Patients presenting with Inappropriate exertional dyspnea should undergo maximal effort-limited exercise testing with or without adjunctive imaging as dictated by current guidelines.

Athletic Performance Decrement

  1. TTE should be performed for CA presenting with athletic performance decrement when medical history, physical examination, 12-lead electrocardiography, or routine bloodwork yield one or more findings suggestive of myocardial, coronary, or valvular pathology or when no clear explanation can be ascertained from the initial evaluation.
  2. The use of exercise testing and CTA/MRI imaging should be considered on a case-by-case basis among CA presenting with athletic performance as dictated by suspected or confirmed pathology.
CA, Competitive athlete(s); CMR, Cardiac magnetic resonance imaging; CTA, Computed tomography angiography; CVD, Cardiovascular disease; EICR, Exercise-induced cardiac remodeling; LA, Left atrium/left atrial; LV, Left ventricle/left ventricular; RA, Right atrium/right atrial; RV, Right ventricle/right ventricular; SCD, Sudden cardiac death; TTE, Transthoracic echocardiography/echocardiogram

Recommendation Grading

Overview

Title

Use of Multimodality Cardiovascular Imaging in Young Adult Competitive Athletes

Authoring Organizations

American Society of Echocardiography

Society of Cardiovascular Computed Tomography

Publication Month/Year

May 1, 2020

Last Updated Month/Year

August 29, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Radiology services

Intended Users

Radiology technologist, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention

Diseases/Conditions (MeSH)

D003952 - Diagnostic Imaging, D054874 - Athletic Performance

Keywords

echocardiography, Pre-participation screening, Competitive Athletes

Source Citation

Baggish AL, Battle RW, Beaver TA, Border WL, Douglas PS, Kramer CM, Martinez MW, Mercandetti JH, Phelan D, Singh TK, Weiner RB, Williamson E. Recommendations on the Use of Multimodality Cardiovascular Imaging in Young Adult Competitive Athletes: A Report from the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2020 May;33(5):523-549. doi: 10.1016/j.echo.2020.02.009. PMID: 32362332.