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Discrimination between physiologic and pathologic left ventricular dilatation
International Journal of Cardiology 109 (2006) 288 – 290 www.elsevier.com/locate/ijcard
Letter to the Editor
Discrimination between physiologic and pathologic left ventricular dilatation Hulya Akhan Kasikcioglu a,T, Erdem Kasikcioglu b, Huseyin Oflaz c, Sennur Unal a, Berrin Topcu b, Zeynep Tartan a, Armagan Arslan b, Nese Cam a, Abidin Kayserilioglu b a
Division of Cardiology, Siyami Ersek Cardiovascular Surgery Center, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey b Department of Sport Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey c Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey Received 28 March 2005; received in revised form 3 April 2005; accepted 14 May 2005 Available online 23 June 2005
Abstract The identification of certain cardiovascular disease in athletes may constitute the basis for disqualification from competition in an effort to minimize the risk of sudden cardiac death. The aim of this study was to assess diastolic and systolic parameters measured by tissue Doppler imaging in endurance veteran athletes who had prominent cardiac dilatation and patients with idiopathic dilated cardiomyopathy in order to determine whether these variables might differentiate each other. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Cardiomyopathy; Athlete’s heart; Tissue Doppler; Echocardiography
1. Introduction
2. Methods
In a sample of highly trained athletes, left ventricular (LV) cavity dimension varied widely but was strikingly increased to a degree compatible with primary dilated cardiomyopathy [1]. Idiopathic dilated cardiomyopathy (DCM) is also an important cause of sudden death among young athletes [2]. The differentiation of physiologic and pathologic cardiac enlargement is important in determining the presence or absence of cardiac disease in athletes in order to prevent exercise-related sudden cardiac death [2]. We designed this study to test the hypothesis that assessment of longitudinal function by tissue Doppler imaging (TDI) may provide an echocardiographic criterion that can differentiate between physiologic and pathologic LV enlargement.
Forty-six male subjects were enrolled in the study: the study population consisted of 11 male patients with an echocardiographic diagnosis of idiopathic DCM who were already undergoing therapy, defined as an M-mode LVDd > 60 mm [3]. Patients were excluded from the study if they had primary valvular heart disease, congenital heart disease, acute and subacute coronary artery disease. Although we screened 71 veteran athletes (age > 35 years) by echocardiography, LVDd was enlarged in 14 participants (19.7%). Furthermore, 21 men matched for age served as a control group. All subjects were in sinus rhythm and did not take any medication due to acute and chronic diseases. Echocardiograms were obtained using commercially available ultrasound equipment (System FiVe, Horten, Norway). The echocardiographic techniques and calculations of different cardiac dimension and volumes were performed according to the recommendations of the American Society of Echocardiography [4]. Peak early wave velocity (E) and peak late wave velocity (A) were
* Corresponding author. Resitpasa caddesi Salkim sokak No=2/5 (PK 9), Avcilar, 34840 Istanbul, Turkey. E-mail address: [email protected] (H.A. Kasikcioglu). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.05.027
H.A. Kasikcioglu et al. / International Journal of Cardiology 109 (2006) 288 – 290
patient athlete
35
control 25
E/Em
measured at the mitral inflow pattern; furthermore, peak velocities during systole (S m), early diastole (E m), late diastole (A m) were measured at the lateral myocardial segment from the four-chamber view by TDI [5]. Results are presented as mean value T SD. Differences between groups were tested for significance using analysis of variance. Sensitivity and specificity were assessed in standard manner.
289
15
3. Results The two groups of the study were similar with regard to height, weight and body surface area (Table 1). Patients with DCM had lower systolic and diastolic velocities than those of athletes and controls. However, the mean E / E m ratio of the athletes was significantly lower than those of patients and controls (Table 1). The E / E m ratio (cut off value = 15) was the best parameter for differentiating pathologic from physiologic cardiac dilatation (sensitivity 86%, spesifity 93%) (Fig. 1).
4. Discussion Although the absolute LV cavity dimension is increased by systematic training in most athletes, very rarely, the distinguishing excessive cardiac adaptations to exercise from structural heart disease is a diagnostic dilemma [6 – 8]. Pathologic cardiac enlargement results from maladaptation of the heart to overload, while physiologic hypertrophy can be considered as a normal adaptation to a chronic pressure or volume overload [8]. Several studies demonstrated that LV end diastolic dimension was 60 mm in 14% –41% of athletes within the range of DCM [1,7]. They indicate that a large LV end-diastolic dimension does not
Table 1 The characteristics and echocardiographic parameters of the study groups Patients (n = 11) Athletes (n = 14) Controls (n = 21) Age (year) 52 T 8 BSA (m2) 1.75 T 0.12 HR (beat/min)*,.,81 T10 LVDd (cm)*,6.34 T 0.18 FS (%)*,. 16 T 5 E (cm/s) 111 T16 A (cm/s) 36 T 7 E m (cm/s)*,.,6.14 T 1.88 5.89 T 1.41 A m (cm/s) S m (cm/s)*,.,5.29 T 0.74 E / E m *,.,19.43 T 6.07
48 T 6 1.75 T 0.12 61 T 6 6.22 T 0.13 23 T 5 97 T 15 39 T 8 9.66 T 2.40 6.08 T 0.86 9.24 T 1.59 9.93 T 2.80
51 T 7 1.73 T 0.09 74 T 8 5.33 T 0.20 21 T 4 98 T 16 41 T10 8.23 T 1.06 6.02 T 0.96 7.74 T 1.17 12.46 T 2.97
Values are mean T SD; *, p < 0.05, patients vs. controls; ., athletes vs. patients; -, athletes vs. controls; BSA, body surface area; HR, heart rate; LVDd, left ventricular diastolic diameter; FS, fractional shortening; E, early diastolic peak flow velocity; A, late diastolic peak flow velocity; E m, peak velocity of early myocardial diastolic wave; A m, peak velocity of late myocardial diastolic wave; S m, peak velocity of myocardial systolic wave.
5 25
50
75
100
Normal Distribution (%) Fig. 1. Probability scale of peak early diastolic velocity of mitral inflow (E) / peak early diastolic velocity of myocardial motion (E m) and the best cut-off value of E / E m for differentiating between patients and athletes.
distinguish pathologic conditions from physiologic adaptation in every time. Previous studies show that TDI analysis may help to solve of the determination problem in hypertrophied heart [5]. The results showed that establishment of E / E m in athletes may be used in clinical practice since it is a useful method for the differentiation of pathologic and physiologic LV dilatation. The E wave velocity by E m provides an alternative method to correct the transmitral velocity for the influence of relaxation [9]. It is also reported that an excellent correlation between E / E m and mean pulmonary wedge pressure in patients with heart failure [9]. Athletes with increased LV dimensions in the gray zone cause a crucial problem concerning the differential diagnosis between athlete’s heart and structural heart disease [1,2,7]. DCM may present with an enlarged LV cavity dimension before clinical expression develops with onset of symptoms and hemodynamic deterioration, even sometimes in athletes [10]. The 15 cut off for E / E m is taken as a single indicator, is a very sensitive and specific variable to differentiate patients with DCM from athletes or agematched controls. As a consequence, the diastolic parameters (especially E / E m) measured by TDI may be used successfully to distinguish pathologic and physiologic cardiac enlargement if LV cavity diameter is within gray scale.
References [1] Pelliccia A, Culasso F, Di Paolo FM, Maron BJ. Physiologic left ventricular cavity dilatation in elite athletes. Ann Intern Med 1999; 130:23 – 31. [2] Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. Clinical, demographic and pathologic profiles. J Am Med Assoc 1986;276:199 – 204. [3] Gavazzi A, De Maria R, Renosto G, et al, on behalf of the SPIC (Italian Multicenter Cardiomyopathy Study) Group. The spectrum of left ventricular size in dilated cardiomyopathy: clinical correlates and prognostic implications. Am Heart J 1993;125:410 – 22.
290
H.A. Kasikcioglu et al. / International Journal of Cardiology 109 (2006) 288 – 290
[4] Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricular by two-dimensional echocardiography. American Society of Echocardiography committee on standards, subcommittee on quantitation of two-dimensional echocardiograms. J Am Soc Echocardiogr 1989;2:358 – 67. [5] Vinereanu D, Florescu N, Sculthorpe N, Tweddel AC, Stephens MR, Fraser AG. Differentiation between pathologic and physiologic left ventricular hypertrophy by tissue Doppler assessment of long-axis function in patients with hypertrophic cardiomyopathy or systemic hypertension and in athletes. Am J Cardiol 2001;88:53 – 8. [6] Maron BJ. How should we screen competitive athletes for cardiovascular disease? Eur Heart J 2005;26:428 – 30. [7] Kinoshita N, Onishi S, Yamamoto S, et al. Unusual left ventricular dilatation without functional or biochemical impairment in normoten-
sive extremely overweight Japanese professional sumo wrestlers. Am J Cardiol 2003;91:699 – 703. [8] Maron BJ, Pelliccia A, Spirito P. Cardiac disease in young trained athletes: insights into methods for distinguishing athlete’s heart from structural heart disease, with particular emphasis on hypertrophic cardiomyopathy. Circulation 1995;91:1596 – 601. [9] Garcia MJ, Ares MA, Asher C, Rodriguez L, Vandervoort P, Thomas JD. An index of early left ventricular filling that combined with pulsed Doppler peak E velocity may estimate capillary wedge pressure. J Am Coll Cardiol 1997;29:448 – 54. [10] Redfield MM, Gersh BJ, Bailey KR, Rodeheffer RJ. Natural history of incidentally discovered, asymptomatic idiopathic dilated cardiomyopathy. Am J Cardiol 1994;74:737 – 9.
Letter to the Editor
Discrimination between physiologic and pathologic left ventricular dilatation Hulya Akhan Kasikcioglu a,T, Erdem Kasikcioglu b, Huseyin Oflaz c, Sennur Unal a, Berrin Topcu b, Zeynep Tartan a, Armagan Arslan b, Nese Cam a, Abidin Kayserilioglu b a
Division of Cardiology, Siyami Ersek Cardiovascular Surgery Center, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey b Department of Sport Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey c Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey Received 28 March 2005; received in revised form 3 April 2005; accepted 14 May 2005 Available online 23 June 2005
Abstract The identification of certain cardiovascular disease in athletes may constitute the basis for disqualification from competition in an effort to minimize the risk of sudden cardiac death. The aim of this study was to assess diastolic and systolic parameters measured by tissue Doppler imaging in endurance veteran athletes who had prominent cardiac dilatation and patients with idiopathic dilated cardiomyopathy in order to determine whether these variables might differentiate each other. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Cardiomyopathy; Athlete’s heart; Tissue Doppler; Echocardiography
1. Introduction
2. Methods
In a sample of highly trained athletes, left ventricular (LV) cavity dimension varied widely but was strikingly increased to a degree compatible with primary dilated cardiomyopathy [1]. Idiopathic dilated cardiomyopathy (DCM) is also an important cause of sudden death among young athletes [2]. The differentiation of physiologic and pathologic cardiac enlargement is important in determining the presence or absence of cardiac disease in athletes in order to prevent exercise-related sudden cardiac death [2]. We designed this study to test the hypothesis that assessment of longitudinal function by tissue Doppler imaging (TDI) may provide an echocardiographic criterion that can differentiate between physiologic and pathologic LV enlargement.
Forty-six male subjects were enrolled in the study: the study population consisted of 11 male patients with an echocardiographic diagnosis of idiopathic DCM who were already undergoing therapy, defined as an M-mode LVDd > 60 mm [3]. Patients were excluded from the study if they had primary valvular heart disease, congenital heart disease, acute and subacute coronary artery disease. Although we screened 71 veteran athletes (age > 35 years) by echocardiography, LVDd was enlarged in 14 participants (19.7%). Furthermore, 21 men matched for age served as a control group. All subjects were in sinus rhythm and did not take any medication due to acute and chronic diseases. Echocardiograms were obtained using commercially available ultrasound equipment (System FiVe, Horten, Norway). The echocardiographic techniques and calculations of different cardiac dimension and volumes were performed according to the recommendations of the American Society of Echocardiography [4]. Peak early wave velocity (E) and peak late wave velocity (A) were
* Corresponding author. Resitpasa caddesi Salkim sokak No=2/5 (PK 9), Avcilar, 34840 Istanbul, Turkey. E-mail address: [email protected] (H.A. Kasikcioglu). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.05.027
H.A. Kasikcioglu et al. / International Journal of Cardiology 109 (2006) 288 – 290
patient athlete
35
control 25
E/Em
measured at the mitral inflow pattern; furthermore, peak velocities during systole (S m), early diastole (E m), late diastole (A m) were measured at the lateral myocardial segment from the four-chamber view by TDI [5]. Results are presented as mean value T SD. Differences between groups were tested for significance using analysis of variance. Sensitivity and specificity were assessed in standard manner.
289
15
3. Results The two groups of the study were similar with regard to height, weight and body surface area (Table 1). Patients with DCM had lower systolic and diastolic velocities than those of athletes and controls. However, the mean E / E m ratio of the athletes was significantly lower than those of patients and controls (Table 1). The E / E m ratio (cut off value = 15) was the best parameter for differentiating pathologic from physiologic cardiac dilatation (sensitivity 86%, spesifity 93%) (Fig. 1).
4. Discussion Although the absolute LV cavity dimension is increased by systematic training in most athletes, very rarely, the distinguishing excessive cardiac adaptations to exercise from structural heart disease is a diagnostic dilemma [6 – 8]. Pathologic cardiac enlargement results from maladaptation of the heart to overload, while physiologic hypertrophy can be considered as a normal adaptation to a chronic pressure or volume overload [8]. Several studies demonstrated that LV end diastolic dimension was 60 mm in 14% –41% of athletes within the range of DCM [1,7]. They indicate that a large LV end-diastolic dimension does not
Table 1 The characteristics and echocardiographic parameters of the study groups Patients (n = 11) Athletes (n = 14) Controls (n = 21) Age (year) 52 T 8 BSA (m2) 1.75 T 0.12 HR (beat/min)*,.,81 T10 LVDd (cm)*,6.34 T 0.18 FS (%)*,. 16 T 5 E (cm/s) 111 T16 A (cm/s) 36 T 7 E m (cm/s)*,.,6.14 T 1.88 5.89 T 1.41 A m (cm/s) S m (cm/s)*,.,5.29 T 0.74 E / E m *,.,19.43 T 6.07
48 T 6 1.75 T 0.12 61 T 6 6.22 T 0.13 23 T 5 97 T 15 39 T 8 9.66 T 2.40 6.08 T 0.86 9.24 T 1.59 9.93 T 2.80
51 T 7 1.73 T 0.09 74 T 8 5.33 T 0.20 21 T 4 98 T 16 41 T10 8.23 T 1.06 6.02 T 0.96 7.74 T 1.17 12.46 T 2.97
Values are mean T SD; *, p < 0.05, patients vs. controls; ., athletes vs. patients; -, athletes vs. controls; BSA, body surface area; HR, heart rate; LVDd, left ventricular diastolic diameter; FS, fractional shortening; E, early diastolic peak flow velocity; A, late diastolic peak flow velocity; E m, peak velocity of early myocardial diastolic wave; A m, peak velocity of late myocardial diastolic wave; S m, peak velocity of myocardial systolic wave.
5 25
50
75
100
Normal Distribution (%) Fig. 1. Probability scale of peak early diastolic velocity of mitral inflow (E) / peak early diastolic velocity of myocardial motion (E m) and the best cut-off value of E / E m for differentiating between patients and athletes.
distinguish pathologic conditions from physiologic adaptation in every time. Previous studies show that TDI analysis may help to solve of the determination problem in hypertrophied heart [5]. The results showed that establishment of E / E m in athletes may be used in clinical practice since it is a useful method for the differentiation of pathologic and physiologic LV dilatation. The E wave velocity by E m provides an alternative method to correct the transmitral velocity for the influence of relaxation [9]. It is also reported that an excellent correlation between E / E m and mean pulmonary wedge pressure in patients with heart failure [9]. Athletes with increased LV dimensions in the gray zone cause a crucial problem concerning the differential diagnosis between athlete’s heart and structural heart disease [1,2,7]. DCM may present with an enlarged LV cavity dimension before clinical expression develops with onset of symptoms and hemodynamic deterioration, even sometimes in athletes [10]. The 15 cut off for E / E m is taken as a single indicator, is a very sensitive and specific variable to differentiate patients with DCM from athletes or agematched controls. As a consequence, the diastolic parameters (especially E / E m) measured by TDI may be used successfully to distinguish pathologic and physiologic cardiac enlargement if LV cavity diameter is within gray scale.
References [1] Pelliccia A, Culasso F, Di Paolo FM, Maron BJ. Physiologic left ventricular cavity dilatation in elite athletes. Ann Intern Med 1999; 130:23 – 31. [2] Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. Clinical, demographic and pathologic profiles. J Am Med Assoc 1986;276:199 – 204. [3] Gavazzi A, De Maria R, Renosto G, et al, on behalf of the SPIC (Italian Multicenter Cardiomyopathy Study) Group. The spectrum of left ventricular size in dilated cardiomyopathy: clinical correlates and prognostic implications. Am Heart J 1993;125:410 – 22.
290
H.A. Kasikcioglu et al. / International Journal of Cardiology 109 (2006) 288 – 290
[4] Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricular by two-dimensional echocardiography. American Society of Echocardiography committee on standards, subcommittee on quantitation of two-dimensional echocardiograms. J Am Soc Echocardiogr 1989;2:358 – 67. [5] Vinereanu D, Florescu N, Sculthorpe N, Tweddel AC, Stephens MR, Fraser AG. Differentiation between pathologic and physiologic left ventricular hypertrophy by tissue Doppler assessment of long-axis function in patients with hypertrophic cardiomyopathy or systemic hypertension and in athletes. Am J Cardiol 2001;88:53 – 8. [6] Maron BJ. How should we screen competitive athletes for cardiovascular disease? Eur Heart J 2005;26:428 – 30. [7] Kinoshita N, Onishi S, Yamamoto S, et al. Unusual left ventricular dilatation without functional or biochemical impairment in normoten-
sive extremely overweight Japanese professional sumo wrestlers. Am J Cardiol 2003;91:699 – 703. [8] Maron BJ, Pelliccia A, Spirito P. Cardiac disease in young trained athletes: insights into methods for distinguishing athlete’s heart from structural heart disease, with particular emphasis on hypertrophic cardiomyopathy. Circulation 1995;91:1596 – 601. [9] Garcia MJ, Ares MA, Asher C, Rodriguez L, Vandervoort P, Thomas JD. An index of early left ventricular filling that combined with pulsed Doppler peak E velocity may estimate capillary wedge pressure. J Am Coll Cardiol 1997;29:448 – 54. [10] Redfield MM, Gersh BJ, Bailey KR, Rodeheffer RJ. Natural history of incidentally discovered, asymptomatic idiopathic dilated cardiomyopathy. Am J Cardiol 1994;74:737 – 9.