Turk Kardiyol Dern Ars. 2016; 44(1): 1-21 | DOI: 10.1093/ehjci/jeu323

The multi-modality cardiac imaging approach to the Athlete's heart: an expert consensus of the European Association of Cardiovascular Imaging

Maurizio Galderisi¹, Nuno Cardim², Antonello D’andrea³, Oliver Bruder⁴, Bernard Cosyns⁵, Laurent Davin⁶, Erwan Donal⁷, Thor Edvardsen⁸, Antonio Freitas⁹, Gilbert Habib¹⁰, Anastasia Kitsiou¹¹, Sven Plein¹², Steffen E. Petersen¹³, Bogdan A. Popescu¹⁴, Stephen Schroeder^15
1Department of Advanced Biomedical Sciences, Federico II Universite Hastanesi, Napoli, Italya
²Cardiac Imaging Department, HospitalDaLuz, Lisbon, Portugal
³Department of Cardiology, Second University of Naples, AORN dei Colli, Monaldi Hospital, Naples, Italy
⁴Department of Cardiology and Angiology, Contilia Heart and Vascular Center, Elisabeth Hospital Essen, Essen, Germany
⁵Department of Cardiology, Universtair Ziekenhuis Brussel, Centrum Voor Hart-en Vaatziekten and CHIREC, Brussels, Belgium
⁶Department of Cardiology, Interventional and Cardiovascular Imaging, University of Liege Hospital, Liege, Belgium
⁷Department of Cardiology, Hospital Pontchaillou – University Medical Center, Rennes, France
⁸Department of Cardiology, Center of Cardiologic Innovation, Oslo University Hospital & University of Oslo, Oslo, Norway
⁹Cardiology Department, Hospital Fernando Fonseca, Amadora, Portugal
¹⁰Cardiology Department, APHM, La Timone Hospital and Aix-Marseille Universite`, Marseille, France
¹¹Cardiology Department, Sismanoglio Hospital, Athens, Greece
¹²Multidisciplinary Cardiovascular Research Center & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
¹³NIHR Cardiovascular Biomedical Research Unit at Barts, William Harvey Research Institute, QueenMary University of London, London, UK
¹⁴University of Medicine and Pharmacy“Carol Davila” - Euroecolab, Institute of Cardiovascular Diseases “Prof.Dr. C. C. Iliescu”, Bucharest, Romania
¹⁵Department of Cardiology, Alb-Fils-Kliniken Goeppingen, Germany

The term ‘athlete's heart’ refers to a clinical picture characterized by a slow heart rate and enlargement of the heart. A multi-modality imaging approach to the athlete's heart aims to differentiate physiological changes due to intensive training in the athlete's heart from serious cardiac diseases with similar morphological features. Imaging assessment of the athlete's heart should begin with a thorough echocardiographic examination. Left ventricular (LV) wall thickness by echocardiography can contribute to the distinction between athlete's LV hypertrophy and hypertrophic cardiomyopathy (HCM). LV end-diastolic diameter becomes larger (>55 mm) than the normal limits only in end-stage HCM patients when the LV ejection fraction is <50%. Patients with HCM also show early impairment of LV diastolic function, whereas athletes have normal diastolic function. When echocardiography cannot provide a clear differential diagnosis, cardiac magnetic resonance (CMR) imaging should be performed. With CMR, accurate morphological and functional assessment can be made. Tissue characterization by late gadolinium enhancement may show a distinctive, non-ischaemic pattern in HCM and a variety of other myocardial conditions such as idiopathic dilated cardiomyopathy or myocarditis. The work-up of athletes with suspected coronary artery disease should start with an exercise ECG. In athletes with inconclusive exercise ECG results, exercise stress echocardiography should be considered. Nuclear cardiology techniques, coronary cardiac tomography (CCT) and/or CMR may be performed in selected cases. Owing to radiation exposure and the young age of most athletes, the use of CCT and nuclear cardiology techniques should be restricted to athletes with unclear stress echocardiography or CMR.

Keywords: Athlete's heart, Left ventricular hypertrophy, Hypertrophic cardiomyopathy, Idiopathic dilated cardiomyopathy, Arrhythmogenic right ventricular cardiomyopathy, Echocardiography, Cardiac magnetic resonance, Coronary cardiac CT, Nuclear cardiology

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