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Medical Evaluation of Athletes: Further Imaging Modalities—Stress Echo, CT and MRI

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Textbook of Sports and Exercise Cardiology

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Abstract

Advanced cardiac imaging modalities such as stress echocardiography, computed tomography coronary angiography (CTCA) and cardiac magnetic resonance imaging (CMR) have emerged as valuable tools in the diagnostic work-up and risk stratification of athletes and highly active people with clinical suspicion of cardiac pathology. The choice of imaging modality depends on the clinical appraisal and should be selected to suit the patient’s individual circumstances. When interpreting imaging findings in athletes it is important to have a thorough understanding of the normal structural and functional adaptations that accompany different forms of exercise. Atypical findings, such as marked cardiac dilation with borderline ejection fraction, extensive coronary artery calcification or small patches of late gadolinium enhancement may be commonly encountered in apparently healthy athletes and require careful interpretation in relation to other clinical findings. In this chapter we will highlight state-of-the-art stress echocardiography, computed tomography coronary angiography and cardiac magnetic resonance imaging techniques and propose a framework for the implementation of these techniques in the work-up of athletes with symptoms suggestive of underlying cardiovascular pathology and in asymptomatic athletes with abnormalities detected during screening evaluation. We will discuss findings that are frequently encountered in highly trained athletes and how to distinguish these from patients with underlying pathologies such as cardiomyopathies and coronary artery disease.

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Authors and Affiliations

  1. Department of Cardiovascular Medicine, University Hospital Leuven, Leuven, Belgium

    Guido Claessen

  2. Department of Sports Cardiology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia

    Guido Claessen & André La Gerche

  3. National Centre for Sports Cardiology, St. Vincent’s Hospital Melbourne, Melbourne, VIC, Australia

    André La Gerche

Authors
  1. Guido Claessen
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  2. André La Gerche
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Corresponding author

Correspondence to André La Gerche .

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

  1. 1.

    A 23-year old professional football player undergoes pre-participation screening. The club wants personal and family history, clinical examination, ECG as well as an echocardiography to be performed. The echo reveals an anomalous right coronary artery with inter-arterial course between the great vessels. All other investigations are negative. As part of further work-up an exercise echocardiogram is performed, which is unremarkable. What is the best management strategy for this athlete?

  2. 2.

    A 35-year old professional cyclist reports episodes of sudden fatigue and loss of power during high-intensity exercise. His medical history is unremarkable. The resting ECG shows features of athlete’s heart, but no ST-segment abnormalities or T-wave inversion. He has no known cardiovascular risk factors and his family history is negative for cardiac diseases and/or sudden cardiac deaths. A resting echocardiogram is within the limits of normal for a highly trained athlete. Exercise testing reveals a superb exercise capacity with a VO2max of 76 ml/min/kg and runs of non-sustained ventricular tachycardia originating from the right ventricular apex. What is the next step in the work-up of this athlete?

  3. 3.

    A 16-year old competitive cyclist undergoes pre-participation screening, which includes an echocardiogram as mandated by the sports federation. The athlete is asymptomatic and his resting ECG is normal. The echocardiogram reveals profound hypertrabeculation of the midventricular-to-apical lateral LV wall with borderline LV systolic function (ejection fraction = 52%). Should the athlete be discouraged from competitive sport?

1.2 Answers

  1. 1.

    Conservative strategy with annual follow-up. As the athlete is entirely asymptomatic and there are no signs of myocardial ischemia, coronary re-implantation is not indicated. Close follow-up is required to ensure timely detection of symptoms or inducible ischemia in the future.

  2. 2.

    Given the presence of exertional symptoms and documented non-sustained ventricular tachycardia, further work-up is mandatory and includes assessment of arrhythmias as well as excluding underlying structural heart disease. A stress echocardiogram was performed, which revealed impaired right ventricular (RV) as well as left ventricular (LV) reserve, but no regional wall motion abnormalities, which makes ischemia as the cause for the arrhythmias unlikely. Cardiac magnetic resonance imaging with delayed gadolinium sequences demonstrated significant (>10% of LV mass) epicardial enhancement of the apical anterolateral LV wall as well as the RV free wall. Given the combination of ventricular arrhythmias, symptoms, significant myocardial fibrosis and impaired biventricular functional reserve, the athlete was referred for implantable cardioverter-defibrillator implantation.

  3. 3.

    Further evaluation should be considered, including stress echocardiography (cardiac reserve) and cardiac magnetic resonance imaging (to evaluate presence of myocardial scar and/or focal abnormalities). In this case, functional reserve of both ventricles was preserved (13% and 17% increase in ejection fraction from rest to peak exercise for LV and RV, respectively). As such, the observed hypertrabeculation is most likely explained by physiological adaptation to intensive endurance exercise. Annual follow-up is provided to ensure timely detection of potential maladaptive remodelling over time.

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Claessen, G., La Gerche, A. (2020). Medical Evaluation of Athletes: Further Imaging Modalities—Stress Echo, CT and MRI. In: Pressler, A., Niebauer, J. (eds) Textbook of Sports and Exercise Cardiology. Springer, Cham. https://doi.org/10.1007/978-3-030-35374-2_9

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