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

Abstract

Competitive athletes (CA) are a rapidly growing population worldwide. Habitual vigorous exercise, a defining characteristic of this population, is a potent stimulus for adaptive structural and functional cardiac remodeling and is an effective way to reduce the risk of cardiovascular disease (CVD). Manifestations of CVD in CA are highly variable ranging from subtle findings during pre-participation cardiovascular screening (PPCS) to collapse or cardiac arrest during exercise. In general, young CA are most commonly affected by congenital and genetic conditions while older CA most commonly harbor acquired CVD. Cardiac imaging using transthoracic echocardiography (TTE), cardiac computed tomography angiography (CTA), and cardiac magnetic resonance imaging (CMR) plays a fundamental role in the care of CA. This document was created to provide clinical imaging specialists with a comprehensive guide for the performance of multimodality imaging in CA.

Shock to the Heart: Psychosocial Implications and Applications of Sudden Cardiac Death in the Young

“…In addition to the inclusion of the ECG in PPS, the potential role of multi-modality imaging, including echocardiography and stress testing, has also been explored to identify asymptomatic young athletes at risk of SCD [38,39]. While their utility for the downstream evaluation of athletes who screen positive is well established, they are generally not included in initial screening algorithms due to concerns over cost and a paucity of the required expertise, which would result in unacceptably high false positive and false negative rates.…”

“…Imaging alone, without the inclusion of an ECG, is not advisable as many conditions associated with SCD, such as the channelopathies, would be missed. While some advocate for the inclusion of a limited transthoracic echo or point of care ultrasound [40], the diagnostic accuracy and impact on outcomes of this approach has yet to be proven [39].…”

Imaging Considerations for the Athletically Conditioned Heart: An Echocardiography-Focused Overview of the 2020 American Society of Echocardiography Recommendations on the Use of Multimodality Cardiovascular Imaging in Young Adult Competitive Athletes

“…As Dr. Baggish et al summarized nicely, endurance activities introduce a volume challenge, whereas short, high-intensity strength efforts exert a pressure challenge. 2 Activity requires adequate oxygen delivery to tissues to meet the metabolic demands of working muscle (both skeletal and cardiac). Cardiac output (CO) increases to satisfy demand in all individuals who engage in activity through an increase in HR.…”

“…10 We purposefully emphasize the importance of ventricular filling and diastolic function, because the main echocardiographic changes seen in athlete hearts include chamber dilation and enhanced diastolic function to achieve these sometimes remarkable increases in SV. 2…”

“…This document addresses the macroscopic adaptations to various stimuli and helps differentiate between physiologic adaptations and pathologic disease states. 2 With this editorial, we aim to provide a clinically relevant overview of the new ASE guideline document for the cardiothoracic anesthesiologist, with a primary focus on the physiologic adaptations resulting from a variety of athletic stimuli, ranging from powerlifting to alpine ultra-marathons. We will cover pertinent imaging considerations (with an emphasis on echocardiography), the differentiation of physiologic adaptations from pathologic remodeling in athletes, in addition to common cardiovascular concerns, symptoms, and diseases that may be encountered in competitive athletes.…”