European Heart Journal Advance Access originally published online on July 31, 2007
European Heart Journal 2007 28(19):2415-2416; doi:10.1093/eurheartj/ehm307
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Gray zone problem in athletes
Department of Sports Medicine
Istanbul Faculty of Medicine
Istanbul University
Resitpasa caddesi Salkim sokak, No. 2/5 (PK 9) Avcilar
Istanbul 34840
Turkey
Tel: +90 216 3405316 Fax: +90 216 3405316 E-mail address: ekasikcioglu{at}yahoo.com
Sudden death is the most unpleasant complication of hypertrophic cardiomyopathy (HCM), which is the leading cause of cardiac death in athletes. The accurate diagnosis of HCM is a more important problem than its risk stratification profile.1,2 An early and correct diagnosis of HCM, particularly in asymptomatic subjects, is crucial during pre-participation screening in athletes. However, detection of an increased risk group remains to be a major problem with many aspects, including medical, social, ethical, financial, and legal.3 The law allows the medical profession to establish the appropriate nature and scope of pre-participation screening of athletes, based on its collective medical judgement.4 But, financial limitations lead to difficulties in both the diagnosis and designation of recommendations for the screening programmes of many countries in the world.
Recently, Maron5 reported the differentiation criteria between HCM and an athlete's heart, based on the genetic, sexual, morphological, and functional characteristics of these two entities. However, there is no specific sign, symptom, or test for the differentiation between an athlete's heart and HCM. Even though the presence or absence of left ventricular hypertrophy is not an accurate diagnostic criterion, the phenotypic spectrum may be different among individuals with the same mutation.6 It is also well recognized that some gene carriers may not have abnormal ECGs or echocardiograms.
Indeed, based on the data of the Italian national pre-participation screening programme, it may be argued that ECG is an effective tool for identifying young athletes with HCM. In addition, according to The European Society of Cardiology Consensus Statement,7 the 12-lead ECG has been proposed as a simple and cheap test for detecting cardiovascular abnormalities. Furthermore, the 12-lead ECG shows a broad range of abnormal patterns in trained athletes; however, the determinants and clinical significance of these abnormal ECG patterns in trained athletes are still uncertain. Also, Pelliccia and Maron8 have demonstrated abnormal ECGs in 40% of the 1005 athletes tested, but structural cardiac diseases were identified in only 5% of these. A specific finding in this study is a lower incidence of grey scale in athletes, even though high prevalence of HCM is thought to be expected in the general population.9 It is often assumed that about 2% of highly trained adult male athletes show mildly increased left ventricular wall thicknesses of 13–15 mm, which define a grey zone where extreme expressions of athlete's heart and mild morphological forms of HCM overlap.
Although echocardiography may not be cost-effective, it is a valuable non-invasive method for differentiating cardiac pathologies other than athlete's heart.10 Echocardiography is not only helpful for the accurate diagnosis of HCM, but also facilitates its risk stratification, such as the level of outflow tract obstruction. Recently, an easily measured tissue Doppler index was proposed as a potentially useful method for distinguishing athlete's heart from structural heart disease.
In conclusion, it is clear that there is still a long way to go for the discrimination of these two entities. However, it appears that evaluation of myocardial function by new echocardiographic techniques may be useful in solving this problem.
References
- Pelliccia A, Maron BJ. Athlete's heart electrocardiogram mimicking hypertrophic cardiomyopathy. Curr Cardiol Rep (2001) 3:147–151.[CrossRef][Medline]
- Pelliccia A, Di Paolo FM, Corrado D, Buccolieri C, Quattrini FM, Pisicchio C, Spataro A, Biffi A, Granata M, Maron BJ. Evidence for efficacy of the Italian national pre-participation screening programme for identification of hypertrophic cardiomyopathy in competitive athletes. Eur Heart J (2006) 27:2196–2200.
[Abstract/Free Full Text] - Maron BJ. Hypertrophic cardiomyopathy, a systemic review. JAMA (2002) 287:1308–1320.
[Abstract/Free Full Text] - Maron BJ. How should we screen competitive athletes for cardiovascular disease. Eur Heart J (2005) 26:428–430.
[Free Full Text] - Kasikcioglu E. A crucial point: the early diagnosis of increased risk subjects before sudden cardiac death. Int J Sports Med (2004) 25:641–642.[CrossRef][Web of Science][Medline]
- Maron BJ, Thompson PD, Puffer JC, McGrew CA, Strong WB, Douglas PS, Clark LT, Mitten MJ, Crawford MH, Atkins DL, Driscoll DJ, Epstein AE. Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association. Circulation (1996) 94:850–856.
[Free Full Text] - Maron BJ. Cardiovascular disease in athletes. In: Heart disease—Zipes DP, Libby P, Bonow RO, Braunwald E, eds. (2005) 7th ed. Philadelphia: Elsevier. 1985–1991.
- Maron BJ, Seidman JF, Seidman CE. Proposal for contemporary screening strategies in families with hypertrophic cardiomyopathy. J Am Coll Cardiol (2004) 44:2125–2132.
[Abstract/Free Full Text] - Corrado D, Pelliccia A, Bjornstad HH, Vanhees L, Biffi A, Borjesson M, Panhuyzen-Goedkoop N, Deligiannis A, Solberg E, Dugmore D, Mellwig KP, Assanelli D, Delise P, van-Buuren F, Anastasakis A, Heidbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E, Blomstrom-Lundqvist C, McKenna WJ, Thiene G, Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J (2005) 26:516–524.
[Abstract/Free Full Text] - Kasikcioglu E. The role of echocardiography screening in athletes for cardiovascular disease. Eur J Echocardiogr (2006) 7:182–183.
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