Differentiation between athlete’s heart and dilated cardiomyopathy in athletic individuals

• Published in: Heart (British Cardiac Society) Vol. 106; no. 14; pp. 1059 - 1065
• Main Authors: Millar, Lynne Martina, Fanton, Zephryn, Finocchiaro, Gherardo, Sanchez-Fernandez, Gabriel, Dhutia, Harshil, Malhotra, Aneil, Merghani, Ahmed, Papadakis, Michael, Behr, Elijah R, Bunce, Nick, Oxborough, David, Reed, Matthew, O'Driscoll, Jamie, Tome Esteban, Maria Teresa, D'Silva, Andrew, Carr-White, Gerry, Webb, Jessica, Sharma, Rajan, Sharma, Sanjay
• Format: Journal Article
• Language: English
• Published: England 01.07.2020
• Subjects: idiopathic dilated cardiomyopathy
• ISSN: 1355-6037; 1468-201X
• DOI: 10.1136/heartjnl-2019-316147

ObjectiveDistinguishing early dilated cardiomyopathy (DCM) from physiological left ventricular (LV) dilatation with LV ejection fraction <55% in athletes (grey zone) is challenging. We evaluated the role of a cascade of investigations to differentiate these two entities.MethodsThirty-five asymptomatic active males with DCM, 25 male athletes in the ‘grey zone’ and 24 male athletes with normal LV ejection fraction underwent N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement, ECG and exercise echocardiography. Grey-zone athletes and patients with DCM underwent cardiovascular magnetic resonance (CMR) and Holter monitoring.ResultsLarger LV cavity dimensions and lower LV ejection fraction were the only differences between grey-zone and control athletes. None of the grey-zone athletes had abnormal NT-proBNP, increased ectopic burden/complex arrhythmias or pathological late gadolinium enhancement on CMR. These features were also absent in 71%, 71% and 50% of patients with DCM, respectively. 95% of grey-zone athletes and 60% of patients with DCM had normal ECG. During exercise echocardiography, 96% grey-zone athletes increased LV ejection fraction by >11% from baseline to peak exercise compared with 23% of patients with DCM (p<0.0001). Peak LV ejection fraction was >63% in 92% grey-zone athletes compared with 17% patients with DCM (p<0.0001). Failure to increase LV ejection fraction >11% from baseline to peak exercise or achieve a peak LV ejection fraction >63% had sensitivity of 77% and 83%, respectively, and specificity of 96% and 92%, respectively, for predicting DCM.ConclusionComprehensive assessment using a cascade of routine investigations revealed that exercise stress echocardiography has the greatest discriminatory value in differentiating between grey-zone athletes and asymptomatic patients with DCM. Our findings require validation in larger studies.