Multimodality Cardiovascular Imaging in Young Adult Competitive Athletes

Patient Guideline Summary

Publication Date: May 1, 2020

Last Updated: November 28, 2023

Objective

This patient summary means to discuss key recommendations from the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance for Multimodality Cardiovascular Imaging in Young Adult Competitive Athletes.

Overview

The heart has four chambers. The two on the left receive blood from the lungs and pump it through the aorta to the rest of the body. The two on the right receive blood from the body and pump it to the lungs. The lower chambers are called ventricles; they are surrounded by more muscle than the upper two, the atria. The left ventricle produces a much higher pressure than the right ventricle.
Young athletes occasionally die suddenly when performing their sport.
Early symptoms or suggestive family history may indicate a risk of sudden death in such individuals.
Symptoms include chest discomfort or difficult breathing on exertion, fainting, and collapsing during exercise.
Known causes for sudden death in young athletes include many congenital (present at birth) and acquired conditions that can be identified by medical imaging.
This patient summary focuses on evaluating young athletes suspected of being at risk for sudden death. Several different imaging techniques are available to tell the difference between normal athletic heart changes and abnormalities that need treatment to reduce risk.

Diagnosis

EXERCISE-INDUCED CARDIAC REMODELING (EICR)

Specialists in imaging the heart of a competitive athlete understand how the heart adapts to intense physical training.
This adaptation includes the amount of heart muscle and the size and shape of the heart’s chambers and is influenced by many factors such as duration of training, the sport being trained for and personal factors of the athlete.
Endurance sports commonly enlarge the left ventricle and both atria.
The first part of the aorta may also be mildly enlarged, but more than that may require added imaging studies to detect aortic abnormalities.

DIFFERENTIATING EICR FROM PATHOLOGY
Left Ventricular Wall Thickening

Likewise, excess enlargement of the left heart muscle may also suggest abnormalities.
Ultrasound measurements of the left heart from the esophagus must take care to avoid including right heart structures.
Thickening of the left heart combined with certain blood flow measurements may indicate abnormal remodeling.
If the results of initial studies are unclear, additional imaging studies are indicated.

Left Ventricular Dilation

The first study to be used to measure the left ventricular volume is ultrasound through the esophagus (TTE). If this study suggests an abnormal enlargement of that chamber, a cardiac magnetic resonance imaging (CMR) can confirm the findings.
Even those studies are not enough to inform a treatment plan. A combination of anatomic and blood flow measurements plus symptoms is needed to determine if there is sufficient risk to warrant treatment.

Right Ventricular Dilation

Similar caution applies to right heart enlargement: A combination of imaging studies and symptoms is required to determine if and what treatment is required.

Hypertrabeculation

Trabeculae (structural elements within the heart) may also enlarge in athletes. If so, further testing such as ultrasound using an intravenous enhancing agent or CMR may be required.

PRE-PARTICIPATION CARDIOVASCULAR SCREENING

Prior to entering intensive athletic participation, a focused history and physical exam and, ideally, a 12-lead EKG should be routine for all young competitive athletes. Convenient access to expertise in comprehensive imaging studies and sports medicine should be available to all who have suspicious findings.

THE SYMPTOMATIC COMPETITIVE ATHLETE
Exertional Chest Discomfort

If a competitive athlete has chest pain possibly from the heart, an esophageal ultrasound should be performed.
A maximal effort stress test should also be done. Imaging may be added and should be done immediately after the stress test to detect inadequate blood supply to the stressed heart.
The TTE or subsequent imaging should clearly identify the origin of both left and right coronary arteries as they exit the aorta since abnormalities there could increase risk.

Syncope

Fainting after or without prior exertion is not a sign of heart disease.
However, a competitive athlete who faints during exercise or otherwise requires a thorough heart evaluation using imaging studies.
And a competitive athlete who faints for any other reason requires a maximal effort stress test, possibly including imaging studies.

Palpitations and Arrhythmias

If a competitive athlete has heart pounding or an irregular pulse during exercise, an esophageal ultrasound and a maximal effort stress test should be done.
If a competitive athlete has certain abnormalities on an EKG, an esophageal ultrasound should be done.

Inappropriate Exertional Dyspnea

Competitive athletes who are unusually short of breath after exertion should be tested with an esophageal ultrasound and a maximal effort stress test unless they respond to treatment for a cause like asthma that is not due to the heart.

Athletic Performance Decrement

If a competitive athlete's performance unexpectedly worsens and a complete evaluation including an EKG and blood testing suggests a heart problem, the first test to be done is an esophageal ultrasound. Subsequent imaging or exercise studies should be considered as indicated.

Abbreviations

CCTA: Cardiac Computed Tomography Angiography
CMR: Cardiac Magnetic Resonance
EICR: Exercise-induced Cardiac Remodeling
TTE: Transthoracic Echocardiography

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.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.