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Are right heart reference values right when assessing competitive athletes?

by Luis Serratosa - EAPC Sports Cardiology Section

Risk Factors and Prevention

Certain athletes, specifically those engaged in endurance disciplines, may show right ventricle (RV) dimensions that may overlap with the pathological dilatation of the RV in patients with arrhythmogenic ventricular cardiomyopathy (ARVC). As previously published RV reference values have not included competitive athletes, their use with this population could be misleading and a possible source of misdiagnosis.

The present systematic review and meta-analysis from 46 echocardiography studies (6806 athletes) and 18 cardiac magnetic resonance (CMR) studies (740 athletes), provides with normative echocardiography and CMR reference values for RV dimensions and function, in order to be implemented in the clinical evaluation of competitive athletes. Athletes were classified into strength (such as bodybuilders, weightlifters), endurance (such as long-distance runners, swimmers, cross-country skiers) and combined (such as rowers, cyclists, speed skaters) categories according to the intensity level of static and dynamic components of their training (Mitchell’s classification). A fourth mixed category included heterogeneous groups of athletes of different sports.

The results suggest that the extent of RV remodeling is particularly evident in athletes of combined sports (high static, high dynamic demand), who show greater values of RV areas and basal and midcavity diameters as well as greater values of RV wall thickness. Clinicians should therefore be aware about the potential misleading interpretation of echocardiographic RV assessment in this group of athletes. Functional indexes results suggest that healthy athletes can show a slightly lower RV function at rest and confirm the uncertainties regarding the strict application of functional criteria for the diagnosis of ARVC based on fractional area change.

Echocardiographic and CMR RV size and function normative reference values (95th percentile and lower reference values at the 5th percentile) are provided in well-designed tables, to properly assess the presence and extent of RV dilatation and function in male competitive athletes. Due to small number of studies available in female athletes, just mean ± SE but no normative reference values could be reported.

According to the results of this meta-analysis, the authors confirm that the criteria of RV enlargement proposed by the American Society of Echocardiography cannot be properly applied to athletes, and that in order to avoid unwarranted false-positive results, only the major echocardiographic criteria for the diagnosis of ARVC should be applied.

Applying these new reference values in the daily practice of all those assessing athletes will sure be of help in differentiating the physiological adaptations of the athlete’s right heart from RV cardiomyopathies.

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology




Luis Serratosa commented on this article:

Normative Reference Values of Right Heart in Competitive Athletes: A Systematic Review and Meta-Analysis

D’Ascenzi F, Pelliccia A, Solari M, et al.

J Am Soc Echocardiogr 2017; 30: 845-58.