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The Role of Imaging

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Textbook of Sports and Exercise Cardiology

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Abstract

In athletes of all age groups, the appropriate application of advanced imaging techniques is crucial to detect, graduate and potentially treat cardiovascular conditions that may pose an increased risk for continued sports participation. This primarily refers to the prevention of acute cardiac events such as sudden cardiac death, but also involves the identification of both negative and positive effects on the development and the clinical course of chronic cardiac disorders. This is of particular relevance in recreational/master athletes, since these individuals very often perform strenuous activities such as marathon or triathlon in a non-organized and non-supervised fashion. In addition, recreational/master athletes are usually at least middle-aged and have very often been exposed to elevated cardiovascular risk factor profiles over a longer period of time as compared to young competitive athletes. By means of echocardiography, for example, a common clinical scenario is to differentiate between increased left ventricular wall thickness induced by either long-term intensive exercise training or by hypertension. Coronary computed tomography contributes to advanced risk stratification and to the detection of coronary artery disease as the main cause of SCD in this cohort; this also holds true for exercise echocardiography, nuclear imaging and cardiac magnetic resonance imaging. The latter also identifies regions of myocardial fibrosis that may indicate an increased risk for arrhythmias, either by late gadolinium enhancement or by T1 mapping. Invasive coronary angiography, if indicated according to symptoms or suggestive findings during non-invasive procedures, either confirms or excludes relevant coronary stenosis and allows immediate interventional treatment. Advanced intracoronary artery imaging including intravascular ultrasound or assessment of fractional flow reserve can help to graduate the severity of stenoses and to understand epicardial and intramyocardial microvascular causes of symptoms. However, the need of radiation exposure and contrast agents as well as cost issues require careful risk-benefit assessment, especially in asymptomatic athletes with risk factors.

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Author information

Authors and Affiliations

  1. Private Center of Sports & Exercise Cardiology, Munich, Germany

    Axel Pressler

  2. Clinic of Cardiology and Intensive Care Medicine, Bethanien Hospital Moers, Moers, Germany

    Stefan Möhlenkamp

Authors
  1. Axel Pressler
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  2. Stefan Möhlenkamp
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Correspondence to Stefan Möhlenkamp .

Editor information

Editors and Affiliations

  1. Private Center for Sports and Exercise Cardiology, München, Bayern, Germany

    Axel Pressler

  2. University Institute of Sports Medicine Prevention and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria

    Josef Niebauer

Review

Review

1.1 Questions

A 55-year-old male runner presents in your department for a health exam in order to get written medical clearance required for participation in his next marathon. He had finished 2–3 marathons per year over the past 14 years, after having decided to change his previously unhealthy lifestyle at the age of 40. Until then he was smoking approximately 5–10 cigarettes/day. His father had myocardial infarction at the age of 58. Occasional blood pressure (BP) measurements at his general practitioner had partly revealed borderline systolic values between 130 and 145 mmHg, but when using his wife’s device at home values had always been “normal”. Thus, no medication had been recommended so far. Physical examination was normal, BP was 147/86 mmHg, and resting ECG showed an isolated increased QRS voltage. His LDL-cholesterol was 167 mg/dl (4.3 mmol/l). You decide to perform exercise testing, showing a maximal blood pressure of 230/90 mmHg and a normal ECG. You also decide to perform an echocardiogram, revealing left ventricular size at the upper limit of normal and mild hypertrophy (12 mm).

  1. 1.

    How do you interpret these findings?

  2. 2.

    How could you add additional information regarding the etiology of left ventricular hypertrophy?

  3. 3.

    How would you estimate this runner’s overall cardiovascular risk?

  4. 4.

    Does this patient need additional examinations based on advanced imaging techniques?

In case you have decided to perform CAC, imagine this runner would have a score of 123.

  1. 5.

    Would you treat this patient with statins?

  2. 6.

    Would you advise against continued marathon running?

  3. 7.

    Would you perform additional imaging testing, and if yes, which technique would you use?

  4. 8.

    Would you act different if calcium score was 567?

1.2 Answers

  1. 1.

    The runner was a former smoker but had quit 15 years ago. On the other hand, he has a positive family history of coronary artery disease, and the previous BP measurements were at least borderline, which is regarded high-normal in Europe but already stage I hypertension in the US. The ECG does not further add to these considerations, since isolated increased QRS voltage does at least in young athletes not require additional testing; nonetheless, it could be a sign of BP-induced hypertrophy. Both exercise testing and echocardiography support the suspicion of clinically relevant hypertension.

  2. 2.

    This athlete has a history of longstanding endurance exercise, which may be a sufficient explanation for mild hypertrophy. The assessment of left ventricular diastolic function using tissue Doppler, as well as measuring global longitudinal strain could add to the differentiation between athlete’s heart and hypertensive heart disease (although the latter is still not fully excluded in case of normal values).

  3. 3.

    Given the elevated LDL level, the calculated 10-year-risk using the ASCVD score is 8.2%, and thus relevantly elevated.

  4. 4.

    Apart from ambulatory BP monitoring, which is clearly recommended in this case, additional imaging modalities beyond echocardiography are not absolutely indicated. Nonetheless, according to the latest AHA guidelines on the management of blood cholesterol [26], assessment of CAC maybe considered in this situation and should be discussed with the patient.

  5. 5.

    Studies have suggested a CAC cut-off value of >100 to at least raise increased risk awareness, and a benefit of statin treatment has basically been shown for these patients. Given the positive family history of myocardial infarction, a statin should be recommended to the patient.

  6. 6.

    No, there is generally no contraindication to continued running with respect to these findings, providing the BP situation has been clarified and eventually treated.

  7. 7.

    You could think about performing exercise echocardiography due to its higher sensitivity and specificity in confirming or ruling out ischemia as compared to common exercise testing.

  8. 8.

    The athlete is asymptomatic, and thus there is still no clear indication to further expand the diagnostic work-up, since CAC does not allow any conclusion on the presence of severe coronary stenosis. Nonetheless, this score indicates a high likelihood of a cardiovascular event within the following 2–5 years, and it would be prudent to perform exercise echocardiography, nuclear imaging or perhaps even CCTA if local expertise is available.

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Pressler, A., Möhlenkamp, S. (2020). The Role of Imaging. In: Pressler, A., Niebauer, J. (eds) Textbook of Sports and Exercise Cardiology. Springer, Cham. https://doi.org/10.1007/978-3-030-35374-2_32

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