Echocardiography in Athletes in Primary Prevention of Sudden Death

Abstract

IntroductIonThe European Society of Cardiology (ESC) definition for sudden death (SD) is a nontraumatic, unexpected fatal event occurring within 1 h of the onset of symptoms in an apparently healthy control. If death is not witnessed, the definition applies when the victim was in good health 24 h before the event. [1] Cardiovascular (CV) diseases are responsible for approximately 17 million deaths every year in the world and about 25% of which are sudden cardiac death (SCD). [2] A SD may be defined as a SCD when a congenital, or acquired, potentially fatal cardiac condition was known to be present during life, or autopsy has identified a cardiac or vascular anomaly as the probable cause of the event, or no obvious extra cardiac causes have been identified by postmortem examination, and therefore, an arrhythmic event is a likely cause of death. [1] In last years, the number of sport practitioners has increased by many times. The benefits of sport practice in improving CV health are unquestionable, but an increase in CV events has also been demonstrated during its practice. Therefore, the absolute number of people at risk of SCD during exercise is also increasing. [3] SCD of an athlete is a rare, but tragic event, which devastates families, institutions, the community, and sports medicine team. It is widely publicized by the media with significant social implications, conveying the idea that such an event can be preventable.Sport activity might play a trigger role of cardiac arrest in athletes with structural or electrical heart abnormalities, generating malignant arrhythmias, as ventricular fibrillation. The culprit diseases are often clinically silent and unlikely to be suspected or identified on the basis of spontaneous symptoms. [4] Preparticipation screening (PPS) protocol proposed by the ESC focuses on three points: family and personal history, physical examination, and 12-lead electrocardiogram (ECG), showing Echocardiography is a noninvasive imaging technique useful to provide clinical data regarding physiological adaptations of athlete's heart. Echocardiographic characteristics may be helpful for the clinicians to identify structural cardiac disease, responsible of sudden death during sport activities. The application of echocardiography in preparticipation screening might be essential: it shows high sensitivity and specificity for identification of structural cardiac disease and it is the first-line imagining technique for primary prevention of SCD in athletes. Moreover, new echocardiographic techniques distinguish extreme sport cardiac remodeling from beginning state of cardiomyopathy, as hypertrophic or dilated cardiomyopathy and arrhythmogenic right ventricle dysplasia. The aim of this paper is to review the scientific literature and the clinical knowledge about athlete's heart and main structural heart disease and to describe the rule of echocardiography in primary prevention of SCD in athletes.

Potential role of an athlete-focused echocardiogram in sports eligibility

“…Measurements of LV wall thickness should be executed at end diastole, in parasternal long axis (PLAX) or in parasternal short axis (PSAX) views[ 15 ].…”

“…About 10% of SCD cases have been related to cardiac diseases showing structural but no electrical manifestations[ 14 ]. While in Italy an exercise stress test is mandatory before engaging in competitive sports, transthoracic echocardiography has also been hypothesized to have a role in PPS: it might be a useful, convenient and noninvasive tool to increase diagnostic power of screening evaluation[ 15 ]. Even if echocardiography is frequently adopted as a first-line screening tool for athletes[ 16 ], also by major sporting bodies such a Federation Internationale de Football Association (FIFA) or Union of European Football Association (UEFA), and mainly as a valuable second line investigation to the diagnose malignant cardiac conditions[ 17 , 18 ], it has never been recommended as a first-line screening tool in athletes[ 19 , 20 ], nor included in recent ESC 2020 guidelines on sport cardiology[ 3 ].…”

Advanced cardiac imaging in athlete’s heart: unravelling the grey zone between physiologic adaptation and pathology

“…The second most common cause of SCD in athletes is congenital coronary artery anomalies with origin from the “wrong” aortic sinus. The least common causes (5–8%) include myocarditis, valvular heart disease and ion-channel disorders [ 6 ].…”

“…Echocardiography is a valid and complementary diagnostic tool, which allows a morpho-functional evaluation of the heart, distinguishes physiological from pathological ventricle hypertrophy and identifies regional wall motion abnormalities [ 6 ].…”

Sudden Cardiac Death in Athletes: From the Basics to the Practical Work-Up

“…The RV has larger inflow and outflow dimensions in athletes compared to sedentary controls, with no impairment of the systolic function. Moreover, in highly trained endurance athletes, resting RV global systolic function is measured by fractional area change, and tricuspid annular plane systolic excursion (TAPSE) can be lower [ 52 ].…”