The athlete’s heart is a well-known phenomenon in adults practicing competitive sports. Unfortunately, to date, most of the studies on training-induced cardiac remodelling have been conducted in adults and the current recommendations refer mainly to adult individuals. However, an appropriate interpretation of resting ECG and imaging in children practising sports is crucial, given the possibility of early detect life-threatening conditions and managing therapy and eligibility to sports competitions in the rapidly growing paediatric athlete population. While several articles have been published on this topic in adult athletes, a practical guide for the clinical evaluation of pediatric athletes is still missing. In this critical review, we provided a comprehensive description of the current evidence on training-induced remodeling in pediatric athletes with a practical approach for clinicians on how to interpret the resting 12-lead ECG and cardiac imaging in pediatric athlete. Indeed, given that training may mimic potential cardiovascular disorders, clinicians evaluating children practicing sports should pay attention to the risk of missing a diagnosis of a life-threatening condition. However, this risk should be balanced with the risk of overdiagnosis and unwarranted disqualification from sports practice, when interpreting an ECG as pathological while, on the contrary, it may represent a physiological expression of athlete’s heart. Accordingly, we proposed an algorithm for the evaluation of normal, borderline, and abnormal ECG findings that can be useful for the readers for their daily clinical practice.
Background cardiac amyloidosis (CA) is characterized by an impairment of cardiac diastolic and, in the severe state of the disease, systolic function, with increasing worsening of functional capacity and quality of life (QoL). Six minute walking test (6MWT) and Kansas City Cardiomyopathy Questionnaire (KCCQ) are two well-known and validated methods to assess the impact of heart failure (HF) symptoms and functional capacity. Left atrial strain by speckle tracking echocardiography has emerged as an index of left ventricular (LV) diastolic function and filing pressure, and is also associated with symptoms in HF. However, its possible association with functional capacity and QoL in CA has not yet been investigated. Objectives in this observational pilot study, our aim was to evaluate the relationship of left atrial strain with 6MWT and KCCQ in patients with CA (both AL and ATTR). Methods we enrolled consecutive patients with CA during routine follow up visits. Patients underwent clinical and echocardiographic evaluation. On the same day, 6MWT was performed and KCCQ was administered. Speckle tracking analysis was performed offline by an experienced operator blinded to the other data. Correlation analysis was conducted using Pearsons’ coefficient and linear regression analysis Results overall, 43 patients with CA (25 ATTR, 18 AL) were enrolled. Mean age was 74 ±11, 16% (n=7) were female. Most patients showed normal left ventricular (LV) ejection fraction (55±9) and reduced LV global longitudinal strain (GLS =-12 ± 7%), 32 of them with apical sparing pattern. Mean global peak atrial longitudinal strain (PALS) was 14 (median[IQR]=6.5;23.5), mean 6MWT score = 382±104 and mean KCCQ score= 67 ± 24. Global PALS showed a strong direct correlation with 6MWT (Fig 1, P= 0.4, R2=0.2, p-value=0.032) and a trend towards correlation with KCCQ (P=0.3, p-value=0.06), although not reaching statistical significance, probably due to the low sample size. The correlation between PALS and 6MWT was even stronger in patients with ATTR (p=0.7, R2 0.4; p-value<0.0001). Conclusions our preliminary results show that, global PALS is associated with functional capacity and the burden of HF symptoms in ATTR and AL, suggesting its role as a more objective marker of disease severity in CA. Fig. 1
Funding Acknowledgements Type of funding sources: None. Background cardiac amyloidosis (CA) is characterized by an impairment of cardiac diastolic and, in the severe state of the disease, systolic function, with increasing worsening of functional capacity and quality of life (QoL). Six minute walking test (6MWT) and Kansas City Cardiomyopathy Questionnaire (KCCQ) are two well-known and validated methods to assess the impact of heart failure (HF) symptoms and functional capacity. Left atrial strain by speckle tracking echocardiography has emerged as an index of left ventricular (LV) diastolic function and filing pressure, and is also associated with symptoms in HF. However, its possible association with functional capacity and QoL in CA has not yet been investigated. Objectives in this observational pilot study, our aim was to evaluate the relationship of left atrial strain with 6MWT and KCCQ in patients with CA (both AL and ATTR). Methods we enrolled consecutive patients with CA during routine follow up visits. Patients underwent clinical and echocardiographic evaluation. On the same day, 6MWT was performed and KCCQ was administered. Speckle tracking analysis was performed offline by an experienced operator blinded to the other data. Correlation analysis was conducted using Pearsons’ coefficient and linear regression analysis Results overall, 43 patients with CA (25 ATTR, 18 AL) were enrolled. Mean age was 74 ±11, 16% (n=7) were female. Most patients showed normal left ventricular (LV) ejection fraction (55±9) and reduced LV global longitudinal strain (GLS =−12 ± 7%), 32 of them with apical sparing pattern (Table 1). Mean global peak atrial longitudinal strain (PALS) was 14 (median[IQR]=6.5;23.5), mean 6MWT score = 382 ± 104 and mean KCCQ score= 67 ± 24. Global PALS showed a strong direct correlation with 6MWT (Fig 1, P= 0.4, R2=0.2, p-value=0.032) and a trend towards correlation with KCCQ (R2=0.3, p-value=0.06), although not reaching statistical significance, probably due to the low sample size. The correlation between PALS and 6MWT was even stronger in patients with ATTR (p = 0.7, R2 0.4; p-value<0.0001). Conclusions our preliminary results show that, global PALS is associated with functional capacity and the burden of HF symptoms in ATTR and AL, suggesting its role as a more objective marker of disease severity in CA.
Funding Acknowledgements Type of funding sources: None. Background Training-induced cardiac remodelling is usually accompanied by a harmonic and symmetric adaptation of cardiac chambers. Mild aortic enlargement may be a consequence of intense training, although even the definition of aortic dilatation, particularly in athletes and tall athletes, is sometimes challenging. It is therefore essential to early identify competitive athletes with aortic dilatation to manage this condition appropriately. Purpose This study aimed to test a new parameter for the definition of aortic dilatation in competitive athletes, assessing the balancing cardiac remodelling in athletes through the ratio between the aortic diameter and left ventricular (LV) diameter. Methods Competitive athletes were compared with sedentary subjects and with patients with known aortic dilatation. 1901 subjects who underwent echocardiography from 2019 to 2022 were retrospectively enrolled: 993 athletes (74% males, mean age 26±7 years), 410 sedentary (74.1% males, mean age 29±11 years) and 498 patients with aortic dilatation (74.3% males, mean age 56±7 years). Results Patients with aortic dilatation had both an absolute (39.2±2.4 mm) and indexed (19.4±2.2 mm/m2) aortic diameter larger than athletes (30.6±3.2 mm; 16.1±1.5 mm/m2) and sedentary subjects ( 30.5±3.1 mm; 16.5±1.6 mm/m2), with no statistically significant differences between athletes and sedentary subjects. The ratio between the aortic diameter and LV end-diastolic diameter was lower in athletes (0.59 ± 0.06), compared to sedentary subjects (0.65 ± 0.05) and to patients with aortic dilatation (0.81 ± 0.06). The latter had a significantly higher value than the remaining groups (p <0.05). The analysis of the ROC curves highlighted that the cut-off of the ratio between the aortic root diameter and LV diastolic diameter was 0.71, with a 96% sensitivity and 99% specificity of detecting a pathological aortic dilatation. Conclusions This study tested a new echocardiographic parameter for the definition of an aortic dilatation in competitive athletes. The ratio between aortic diameter and LV end-diastolic diameter, with a cut off of 0.71, demonstrated a good sensitivity and specificity to differentiate between physiological and pathological remodelling of the aorta.
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