Gonzalo Grazioli

Usefulness of Echocardiography in Preparticipation Screening of Competitive Athletes

INTRODUCTION AND OBJECTIVES Despite the established diagnostic value of the electrocardiogram in preparticipation screening of athletes, some cardiac structural changes can be missed, particularly in early disease stages. The aim of this study was to evaluate the prevalence of cardiac structural changes via the systematic use of echocardiography in preparticipation screening of competitive athletes. METHODS Professional athletes or participants in a competitive athletic program underwent a screening that included family and personal medical history, physical examination, electrocardiography, exercise testing, and Doppler echocardiography. RESULTS A total of 2688 athletes (67% men; mean age [standard deviation], 21 [10] years) were included. Most of the echocardiographic evaluations (92.5%) were normal and only 203 (7.5%) showed changes; the most frequent change was left ventricular hypertrophy, seen in 50 athletes (1.8%). Cessation of athletic activity was indicated in 4 athletes (0.14%): 2 for hypertrophic cardiomyopathy (electrocardiography had shown changes that did not meet diagnostic criteria), 1 pectus excavatum with compression of the right ventricle, and 1 significant pulmonary valve stenosis; the rest of the changes did not entail cessation of athletic activity and only indicated periodic monitoring. CONCLUSIONS Although rare, some cardiac structural changes can be missed on physical examination and electrocardiography; in contrast, they are easily recognized with echocardiography. These findings suggest the use of echocardiography in at least the first preparticipation screening of competitive athletes to improve the effectiveness of programs aimed at preventing sudden death in athletes.

Inter-individual variability in right ventricle adaptation after an endurance race.

Background Right ventricle (RV) dysfunction has been described in athletes after endurance races. We aimed to understand and characterize the RV response to endurance exercise, the impact of individual variability and the effects of the amount of exercise. Methods and results Echocardiography was performed in 55 healthy adults at baseline and after a three-stage trail race: short (14 km; n = 17); medium (35 km; n = 21); and long (56 km; n = 17). Standard and speckle tracking echocardiographic assessment of the RV was performed with global and separate analysis of the RV basal (inflow) and apical regions. Although no change was observed in the short distance runners, the RV systolic deformation decreased significantly (p < 0.05) after both the medium length and long races (Δ% RV global strain −7.6 ± 20.1 and −8.7 ± 21.8, respectively) with significant RV dilatation (Δ% RV volume +10.6 ± 9.9 and +15.3 ± 12.8, respectively). The RV basal segment made a major contribution to stroke volume during exercise, showing larger increases in size and strain compared with the apex. Various patterns of RV adaptation to exercise, ranging from increases in both RV segmental strains and sizes to an insufficient increase in size and a decrease in strain, were identified; this individual variability was not correlated with prior training. Conclusion An acute RV impairment was demonstrated after a trail-running race and was related to the amount of exercise. A high inter-individual variability was observed. Differences in RV adaptation patterns were independent of prior training, suggesting the influence was due to other individual factors.

Gender influence on the adaptation of atrial performance to training

Abstract Background: High-intensity training has been associated with atrial remodelling and arrhythmias in men. Our purpose was to analyse atrial performance in female endurance athletes, compared to male athletes and controls. Methods: This was a cross-sectional study. We included four groups: female athletes, females controls, male athletes and male controls. Left (LA) and right atrial (RA) volumes and function were assessed using 2D and speckle-tracking echocardiography to determine peak atrial strain-rate at atrial (SRa) and ventricular contraction (SRs), as surrogates of atrial contractile and reservoir function, respectively. ANOVA and Bonferroni’s statistical tests were used to compare variables among groups. Results: We included 82 subjects, 39 women (19 endurance athletes, 20 controls) and 43 men (22 endurance athletes, 21 controls). Mean age was similar between groups (36.6 ± 5.6 years). Athletes had larger bi-atrial volumes, compared to controls (women, LA 27.1 vs. 15.8 ml/m2, p < 0.001; RA 22.31 vs. 14.2 ml/m2, p = 0.009; men, LA: 25.0 vs. 18.5 ml/m2, p = 0.003; RA 30.8 vs. 21.9 ml/m2, p < 0.001) and lower strain-rate (women, LASRa −1.60 vs. −2.18 s−1, p < 0.001; RASRa −1.89 vs. −2.38 s−1, p = 0.009; men, LASRa −1.21 vs. −1.44 s−1, p = 1; RASRa −1.44 vs. −1.60 s−1, p = 1). However, RA indexed size was lower and bi-atrial deformation greater in female athletes, compared to male athletes. Conclusions: The atria of both male and female athletes shows specific remodelling, compared to sedentary subjects, with larger size and less deformation at rest, particularly for the RA. Despite a similar extent of remodelling, the pattern in women had greater bi-atrial myocardial deformation and smaller RA size.

Prevention of sudden death in adolescent athletes: Incremental diagnostic value and cost-effectiveness of diagnostic tests

Introduction Pre-participation screening in athletes attempts to reduce the incidence of sudden death during sports by identifying susceptible individuals. The objective of this study was to evaluate the diagnostic capacity of the different pre-participation screening points in adolescent athletes and the cost effectiveness of the programme. Methods Athletes were studied between 12–18 years old. Pre-participation screening included the American Heart Association questionnaire, electrocardiogram, echocardiogram, and stress test. The cost of test was established by the Catalan public health system. Results Of 1650 athletes included, 57% were men and mean age was 15.09 ± 1.82 years. Positive findings were identified as follows: in American Heart Association questionnaire 5.09% of subjects, in electrocardiogram 3.78%, in echocardiogram 4.96%, and in exercise test 1.75%. Six athletes (0.36%) were disqualified from participation and 10 (0.60%) were referred for interventional treatment. Diagnostic capacity was assessed by the area under the curve for detection of diseases that motivated disqualification for sport practice (American Heart Association questionnaire, 0.55; electrocardiogram, 0.72; echocardiogram, 0.88; stress test, 0.57). The cost for each athlete disqualified from the sport for a disease causing sudden death was €45,578. Conclusion The electrocardiogram and echocardiogram were the most useful studies to detect athletes susceptible to sudden death, and the stress test best diagnosed arrhythmias with specific treatment. In our country, pre-participatory screening was cost effective to detect athletes who might experience sudden death in sports.

Comments on the Usefulness of Echocardiography in Preparticipation Screening of Competitive Athletes. Response

We appreciate the interest in our article shown by Dr. Zigor adaria and agree with him that echocardiography is a sensitive ethod for the diagnosis of silent heart disease and, specifically, r the identification of the origin of both coronary arteries. wever, in contrast to an earlier report, recent studies seem to ace greater importance on the need for surgical treatment of omalous origin of the right coronary artery and on the finding of is entity during autopsies performed in young athletes. The justification of the added value of the echocardiogram is sed on the moderate sensitivity and specificity of the symptoms, inical signs, and electrocardiogram in the athletic population. We nsider that echocardiography would lend greater sensitivity to e potential diagnoses of heart diseases that cause sudden cardiac ath in young people and adults, while it would also enable the tection of heart diseases that, although not a motive for clusion from sports at the time of the diagnosis, would indicate e need for a closer follow-up. There are data on individuals with cuspid valve, but outcomes under the effect of training are as yet known for most heart diseases. We agree with Dr. Madaria in that the greater diagnostic nsitivity in minor disorders, including ‘‘physiological remodelg,’’ can lead to overdiagnosis or false positives. Even so, we ould also point out that the exact boundary between this ysiological remodeling and disease is often difficult to establish, d may vary from one individual to another. Finally, disqualification from participation in athletic activities a very complex issue, and we agree that we must respect the edom of each individual. However, we consider it essential that l of the relevant information concerning the risk involved be sseminated and that these findings be conveyed to the athlete d to the sporting bodies responsible for the competition who, gether, should decide whether or not the athlete’s participation sports should be interrupted. Undoubtedly, in the recreational tting, the decision is mainly up to the individual. From the nzalo Grazioli, Josep Brugada, and Marta Sitges*