First Formal Guidance Issued on Multimodality Cardiac Imaging in Young Athletes

Recommendations help distinguish exercise-induced remodeling from pathology

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The number of competitive athletes is growing, as is the number of physicians interested in caring for them. But habitual exercise can produce changes in the structure and function of the heart that are easily mistaken for pathology. Now there are new recommendations — the first of their kind — on the use of multimodality cardiovascular imaging to help physicians provide proper screening and diagnosis of young competitive athletes.


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“The interpretation of images in competitive athletes requires a comprehensive understanding of exercise-induced cardiac remodeling and an ability to distinguish the characteristics of this process from findings suggestive of pathology,” says Cleveland Clinic clinical and sports cardiologist Tamanna Singh, MD, who served as a co-author of the recommendations. “Not every physician has this expertise.”

The recommendations document, published in the Journal of the American Society of Echocardiography (2020;33[5]:523-549), is an effort of the American Society of Echocardiography in collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance.

“Whether you are doing pre-participation screenings or treating young athletes in your clinic, our algorithm creates a streamlined, efficient approach designed to prevent inappropriate testing or undertesting,” says Dr. Singh, Co-Director of Cleveland Clinic’s Sports Cardiology Center. “Either of these scenarios can lead down a diagnostic path that may take an athlete out of sport unnecessarily or lead to a missed diagnosis, with tragic results.”

Defining the population

The recommendations use the longstanding definition of a competitive athlete as an individual who participates in a team or individual sport that places a high premium on excellence and achievement and requires systematic, intense exercise and training in preparation for competition.

“Defining this population is key,” says Dr. Singh, “so that you know which individuals are likely to exhibit physiologic cardiac remodeling. This is important, because it’s our job to determine whether it is safe for an athlete to play.”

The recommendations document is presented in easy-to-follow sections and designed to provide a clear direction for physicians when screening asymptomatic competitive athletes prior to participation or when evaluating athletes with symptoms such as exertional chest discomfort, syncope, palpitations, arrhythmias, exertional dyspnea or performance decrement from overtraining.


“If we can make sure the patient undergoes a complete differential diagnosis, it will help with downstream management,” Dr. Singh observes. “You will either be able to reassure the athlete that their symptoms are not indicative of pathology and they may return to their sport without restrictions, or you will be able to tell the patient that there is something wrong.”

A ‘nuanced education’

The recommendations focus on the individual strengths and weaknesses of transthoracic echocardiography, cardiac MRI and cardiac CT angiography. These imaging modalities are considered indispensible in the assessment and management of competitive athletes, as well as in risk stratification and surveillance following disease diagnosis.

Detailed descriptions of the various forms of exercise-induced cardiac remodeling are provided, along with explanations of whether each form is seen in athletes who compete in endurance sports, strength sports or both.

Side-by-side images of normal cardiac anatomy and exercise-induced cardiac remodeling provide what Dr. Singh describes as a nuanced education on normal versus abnormal findings.

The section on differentiating exercise-induced cardiac remodeling from pathology walks physicians through the clinical factors and imaging findings suggestive of such remodeling.

“Exercise-induced cardiac remodeling commonly leads to imaging findings that overlap with common forms of heart muscle disease associated with adverse events in competitive athletes, an area termed the ‘gray zone,’” says Dr. Singh. “Physicians treating competitive athletes will find the four cardinal gray zone imaging findings very helpful in distinguishing exercise-induced remodeling from cardiomyopathy.”


Exceptional, but not exceptions

Despite a widespread misconception that athletes are almost universally healthy and will be for life, they are not immune to cardiovascular disease, Dr. Singh notes.

“Just because competitive athletes can tolerate a large amount of exercise doesn’t mean they don’t have congenital heart disease, genetically mediated cardiovascular abnormalities, hypertension, cardiomyopathy or coronary artery disease,” she points out. “Athletes need to be evaluated.”

Her Cleveland Clinic colleague Leslie Cho, MD, Co-Section Head of Preventive Cardiology and Rehabilitation, concurs. “It’s important to assess cardiovascular risk in athletes, whether they are young or older,” says Dr. Cho. “We are seeing growing numbers of older patients who have been athletes all their lives presenting with cardiac manifestation of athlete’s heart.”

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