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EXPERIMENTAL & CLINICAL CARDIOLOGY
Volume 20, Issue 10, 2014
Title: "Contribution of MRI to differential diagnosis between hypertrophic cardiomyopathy and
athlete‘s heart"
Authors: Alexander Jurko, Jana Mistinova Polakova, Jan Strachan, Milan Minarik, Tomas Jurko,
Ingrid Tonhajzerova and Ingrid Schusterov??
How to reference: Contribution of MRI to differential diagnosis between hypertrophic
cardiomyopathy and athlete's heart/Alexander Jurko, Jana Mistinova Polakova, Jan Strachan, Milan
Minarik, Tomas Jurko, Ingrid Tonhajzerova and Ingrid Schusterov??/Exp Clin Cardiol Vol 20
Issue10 pages 6561-6573 / 2014
Contribution of MRI to differential diagnosis between hypertrophic cardiomyopathy and...
Contribution of MRI to differential
diagnosis between hypertrophic
cardiomyopathy and athlete‘s heart
Original article
____________
Alexander Jurko, jr.1, Jana Mistinova Polakova2, Jan Strachan1, Milan Minarik3, Tomas
Jurko1, Ingrid Tonhajzerova4, Ingrid Schusterova5
1
Pediatric Cardiology Clinic, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
2
Radiology Clinic, Medical Faculty, Comenius University, Bratislava
3
Catholic University in Ruzomberok, Faculty of Health Care, Ruzomberok, Slovakia
4
Department of Physiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
5
Cardiac Surgery Clinic, Eastern Heart Institute, Kosice, Slovakia
Corresponding author:
Ingrid Tonhajzerova, Department of Physiology, Jessenius Faculty of Medicine, Comenius University,
Mala Hora 4, 036 01 Martin, Slovakia, e-mail: [email protected]
© 2013 et al.; licensee Cardiology Academic Press. This is an open access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited .
_______________
Abstract
Differential diagnosis between hypertrophic cardiomyopathy and athlete’s heart remains a continuig
problem in clinical cardiology and sports medicine. On the setting of the correct diagnosis depends
athlete’s future professional career, what at high-level competition sports represents a sensitive and
significant problem. From this reason, there is a ongoing search for new noninvasive methods, that would
allow objective assessment of the discrete differencies between these two entities. The goal of the report is
to present diferential diagnostic problems and to higlight contribution of MRI in the process of setting the
correct diagnosis. We present three athletes, all of them had abnormal hypertrophic myocardial changes
on standard echocardiography without clear differentiation between hypertrophic cardiomyopathy and
athlete’s heart. MRI with gadolinium contrast detected fibrotic changes in two athletes and physiologic
findings in the last one, allowing us to make a correct diagnoses. We suggest, that gadolinium contrast
MRI may be an important method in distinguishing hypertrophic cardiomyopathy and athlete’s heart.
Key words
Exp Clin Cardiol, Volume 20, Issue 10, 2014 - Page 6561
Contribution of MRI to differential diagnosis between hypertrophic cardiomyopathy and...
hypertrophic cardiomyopathy, athlete’s heart, echocardiography, magnetic resonace imaging
______________
1.Introduction
Athlete’s heart represents complex morphological changes of the heart as a result of adaptation to
long-term physical training [1]. It is characterized by an increase of left ventricular mass (up to 40%), left
ventricular wall thickening (up to 20%) and enlargement of left ventricular cavity (up to 20%) [2].
Hypertrophic cardiomyopathy is an autozomal dominat genetic disease characterized by myocardial
hypertrophy in the absence of known conditions, that can cause myocardial hypertrophy [3]. Causative
genetic mutations are identified in 50 – 60 % of cases, so around 40 % of these patients may not be detected
by genetic investigation [4].
European Society of Cardiology recommendations are, that athletes should be excluded from
high level competition sports in case they have probable or confirmed hypertrophic cardiomyopathy
diagnosis, as well as those, with positive genotype findings even with absent phenotypic changes [5].
Genotypic positive individuals without phenotypic changes may continue in recreational sport activities
[6]. However, genetic testing is currently not routinely used in clinical practice, because of high cost.
Differential diagnosis between athlete’s heart and hypertrophic cardiomyopathy is extremely
important, because undiagnosed HCM is one of the most frequent cause of sudden cardiac death in
athletes [7]. Currently, there are still number of problems in making the correct diagnosis and with
increasing number of sudden deaths among athletes, setting a correct diagnosis may be challenging.
The baseline cardiologic assessment of an athlete is electrocardiography. European Society of
Cardiology currently classifies two groups of abnormalities in athletes (Tab. 1) [8].
Group 1: common and with trainig associated
ECG changes (athlete’s heart)
Group 2: uncommon and with training not
associated ECG changes (HCM and other heart
diseases)
Sinus bradycardia
T wave inversion
I.degree AV block
ST segment depression
Incomplete RBBB
Pathologic Q waves
Early repolarization
Left atrium enlargement
Isolated QRS voltage criteria for left ventricular
Left rotation of electrical axis/front left hemiblock
hypertrophy (Sokolow-Lyon, Cornell)
Right rotation of electrical axis/rear left hemiblock
Right ventricular hypertrophy
Ventricular preexcitation
Complete R/LBBB
Long or short QT
Brugada-like early repolarization
Table 1. Classification of ECG abnormalities in athletes.
The gold standard for hypertrophic cardiomyopathy diagnosis is echocardiography. However, it has been
estimated, that in more than 20 % of cases, it can not distinguish hypertrophic cardiomyopathy from
athlete’s heart [9]. Myocardial wall thickness in athlete’s heart is less than 13 mm (or less than 16 mm
Exp Clin Cardiol, Volume 20, Issue 10, 2014 - Page 6562
Contribution of MRI to differential diagnosis between hypertrophic cardiomyopathy and...
in specific disciplines, like cycling, rowing) [10]. In opposite to hypertrophic cardiomyopathy, the cardiac
hypertrophy in athletes is symmetrical. Majority of patients with hypertrophic cardiomyopathy have
asymmetrical septal hypertrophy, defined as a ratio of interventricular septal depth to left ventricular
posterior wall depth more than 1.3 [10]. Finding of dynamic left ventricular outflow tract obstruction or
presence of midventricular obstruction, allows much easier diagnosis [3,7,10]. Myocardial thickness
between 13 and 15 mm is sometimes called a „grey zone“, when the differentiation between hyupertrophic
cardiomyopathy and athlete’s heart is very difficult [9]. For this reason, a diagnostic criteria for patients
with myocardial thickeness between 13 and 15 mm has been published as a guideline (Fig 1) [6,9].
Figure 1. Differential diagnosis of a grey zone thickness [24, modified].
LV = left ventricle, HCM = hypertrophic cardiomyopathy, LVH = left ventricular hypertrophy, LA = left
atrium, Max VO2 = maximal oxygen consumption, ↓ = indicate decreased, plus indicate present, minus
indicate absent
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Contribution of MRI to differential diagnosis between hypertrophic cardiomyopathy and...
Magnetic resonace imaging is currently used for the assessment of morphological, functional and tissue
abnormalities in hypertrophic cardiomyopathy patients, especially for discovering fibrotic myocardial
changes. Based on MRI findings, specific morphological variants of hypertrophic cardiomyopathy has
beeen described [11,12,13]. Gadolinium is used in MRI as a contrast medium for myocardial visualisation.
Gadolinium is picked-up and released by healthy myocardium quickly. In fibrotic myocardium the
contrast stays in longer time and is released slowly. This phenomenon is called late gadolinium
enhancement. This technique allows detection of fibrotic, nonfunctional myocardial areas. The number
and extend of these areas correlate with the interventricular septal thickness, the number of hypokinetic
myocardial segments, the decrease of ejection fraction, the presence of hypertrophic cardiomyopathy
phenotype in young age and the presence of intermitent ventricular tachyarrhythmias. This implies, that
there may be a casual relation between the extend of myocardial fibrosis and severity of HCM, including
the risk for sudden cardiac death. Late gadolinium enhancement showing myocardial fibrosis has been
described in about 60 % of patients with hypertrophic cardiomyopathy [3,12]. Areas of myocardial fibrosis
detected by late gadolinium enhancement can also be found in 50 % of patients with myocardial
hypertrophy secondary to aortic stenosis or arterial hypertension [14]. Important fact is, that the finding of
late gadolinium enhancement in patients with hypertrophic cardiomyopathy has not been associated with
any significant clinical symptoms. MRI with gadolinium contrast may, therefore, be helpful in the
diagnosis of caridomyopathy in asymptomatic patients.
The goal of this article is to point out the specific problems in differentiation of hypertrophic
cardiomyopathy and athlete’s heart on three cases of athletes.
Case 1
Patient is a 15-year-old hockey player, who has been refered to cardiology clinic for arterial
hypertension. He has not been complainig of any problems during physical activity. Family history was
positive for asymmetric left ventricular hypertrophy in his grandmather. There were no sudden deaths in
the family. On physical examination, he was overweight with body mas index 27, he had 3/6 systolic
murmur with maximum on the base and the rest of the exam was without abnormalities. His
electrogardiography showed ST segment elevations in V3 and V4 (Fig 2). Echocardiography revealed
asymmetric left ventricular hypertrophy. Diastolic interventricular septum thickness was 31 mm. There
was mild left ventricular outflow truct obstruction with a gradient of 22 mmHg on Doppler examination
(Fig 3). Concomitant mitral insuficiency was hemodynamically nonsignificant. Cardiac rythm disorders
has been excluded by Holter monitoring. MRI confirmed asymmetric septal hypertrophy and fibrotic
myocardial changes were visible as a late gadolinium enhancement hyperdense areas (Fig 4). Disorders of
wall movement kinetic were not present. Based on the above findings, the diagnosis of hypertrophic
cardiomyopathy was made. Despite patient’s no subjective problems, exclusion from all competitive sport
activities has been recommended.
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Contribution of MRI to differential diagnosis between hypertrophic cardiomyopathy and...
Figure 2. Electrocardiographic examination in patient 1. ST segment elevations in V3 and V4, deep Q in
V3.
ĽK
Figure 3. Echocardiographic examination in patient 1. (A) 2D echocardiography with hypertrophic IVS
(arrow). (B) Echocardiography CM with asymetric left ventricular hypertrophy, intraventricular septum
depth = 31mm, left venticular posterior wall depth = 11mm (arrows).
Case 2
17-year-old football player has been in active competition over the last 6 years. He was not having
any problems during physical activity and his performance has been above average. He was refered to
cardiology clinic because of positive family history. His father has been followed-up for hypertrophic
cardiomyopathy. Physical examination revealed normostenic habitus, body mass index of 25, normal
blood pressure, 2-3/6 systolic murmur with maximum in the third and fourth intercostal space on the left.
ECG was significant for ST segment elevation in V2 – V5 and deep S in V5 and V6 (Fig 5). Arrhytmias
were excluded by Holter monitoring. Chest x-ray was without abnormalities. Echocardiography proved
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Contribution of MRI to differential diagnosis between hypertrophic cardiomyopathy and...
Figure 4. Gadolinium contrast MRI in patient 1. Hyperdense late gadolinium enhancement areas of
myocardial fibrosis (arrows), (A) in anteroseptal area and (B) in area of right ventricular wall attachment.
Figure 5. Electrocardiographic examination in patient 2. ST segment elevation in V2 - V5, deep S in V5,
V6.
mild mitral insuficiency and left ventricular hypertrophy, that seemed to be symmetrical, with
intervenricular septum diameter of 22mm, left ventricular mass 259 g and left ventricular mass index
139g/m2. Doppler recorded only minimal turbulence in the left ventricular outflow tract with 15 mm Hg of
pressure gradient (Fig 6). MRI examination confirmed left ventricular hypertrophy, but also revealed late
gadolinium enhancement postcontrast hyperdense areas (Fig 7,8). Diagnosis of hypertrophic
cardiomyopathy was made, based on positive family history and finding of fibrotic myocardial changes.
Patient was advised to discontinue competetive sport activity.
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Contribution of MRI to differential diagnosis between hypertrophic cardiomyopathy and...
Figure 6. Echocardiography in patient 2. Symetrical left ventricular hypertrophy, interventricular septum
depth = 22 mm
Figure 7. MRI in patent 2. Short heart axis (A) and four-chamber view (B). Present is left ventricular
hypertrophy (arrows), interventricular septum depth 20 mm.
B
Case 3
13-year-old hockey player was sent to cardiology outpatient clinic because of bradycardia. He has
IVS
been asymptomatic, with good tolerance of physical activity and in excelent physical condition. Family
ĽK
history was noncontributory. Physical examination was with physiological findings except for bradycardia
ĽK right
in the 35 – 45 beats per minute range. Electrocardiography showed sinus bradycardia, incomplete
bundle branch block, left frontal hemiblock, wider QRS (133 ms duration), the ST segments were normal
(Fig 9). Sinus bradycardia has been recoreded on Holter monitoring with the lowest frequency during
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Contribution of MRI to differential diagnosis between hypertrophic cardiomyopathy and...
Figure 8. Postcontrast MRI in patient 2. Hyperdense myocardial fibrotic changes (arrow).
Figure 9. ECG of patient 3. Sinus bradycardia, incomplete right bundle branch block, left frontal
hemiblock, wider QRS (133 ms).
sleep of 30 beats per minute associated with first degree atrio-ventricular block. Echocardiography showed
left ventricular hypertrophy with mild assymetry (interventricular septum diameter 12,5 mm and left
ventricular posterior wall diameter 9 mm). Diastolic cardiac function was normal, the systolic function was
slightly decreased with resting left ventricular ejection fraction of 49 %. There was no left ventricular tract
obstruction (Fig 10). MRI has been done in order to exclude hypertrophic cardiomyopathy. The
examination confirmed left ventricular hypertrophy and measured parameters of cardiac enlargement
A
B
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Contribution of MRI to differential diagnosis between hypertrophic cardiomyopathy and...
Figure 10. 2D echocardiophraphy (A) and TM examination (B) in patient 3. Left ventricular hypertrophy
(arows) with interventricular septum depth 12,5 mm and left ventricular posterior wall depth 9mm.
Figure 11. MRI of patient 3. Three-chamber view (A) and in short-axis view (B) with left ventricular
hypertrophy (arrow), interventricular septum thickness 12 mm and no other abnormal morpholgical
changes.
were in accord with echocardiolographical findings (Fig 11). Gadolinium contrast did not reveal any
abnormal morphological changes (Fig 12). Stress bicycle ergometry testing confirmed excellent
performance of the cardiovascular system. Based on the above results, we made a diagnosis of athlete’s
heart. Patient continued in competetive sport activity with closed cardiology follow-up. He is currently 16year-old without any symptoms during trainings or games, but there has been mild increase of the
interventricular septum diameter to 14 mm.
4. Discussion
Athlete’s heart represents a complex of morphological myocardial changes as a adaptation
process to the long term training [1]. The hypertrophy in athlete’s heart is limited to cardiomyocytes, with
enlarged longitudinal and transverse diameters, the interstitial space is without significant changes [15].
Exp Clin Cardiol, Volume 20, Issue 10, 2014 - Page 6569
Contribution of MRI to differential diagnosis between hypertrophic cardiomyopathy and...
Figure 12. Gadolinium contrast MRI of patient 3 with no abnormal postcontrast changes.
Ischemia of hypertrophied left ventricle in athlete’s heart is prevented by an increase in myocardial
mitochondrial number, by normal activity of ATP-ase and by changes at the microcapillary level [16]. The
most important problem is to distinguish athlete’s heart from hypertrophic cardiomyopathy [7].
Hypertrophic cardiomyopathy is an autozomal dominat genetic disease characterized by myocardial
hypertrophy in the absence of known conditions, that can cause myocardial hypertrophy [3].
Hypertrophic cardiomyopathy is also the most frequent causes of sudden cardiac death in athletes [17, 18,
19]. Distinguishing these two entities may create a significant clinical problem. Making a false diagnosis of
hypertrophic cardiomyopathy has the major consequences for an athlete: disqualification from
competetive sports, psychological stress and financial losses. On the other hand, unrecognized
cardiomyopathy can lead to sudden cardiac death. The “gray zone” represents an overlap of marginal
values obtained by measurement of myocardial thickness between athlete’s heart and hypertrophic
cardiomyopathy. The correct diagnosis is especially difficult in these cases [9].
All our presented cases have diagnosed left ventricular hypertrophy by echocardiography.
Recently, an algorithm has been proposed in order to detect conditions with increased risk for sudden
cardiac death [9]. The initial step is detailed history with focus on palpitations, chest pain, dyspnoe and
syncope. Our patients did not have any of these problems. In family history, it is important to specifically
address the presence of sudden death, cardiovascular diseases and hypertrophic cardiomyopathy. Both
our patients with the final diagnosis of hypertrophic cardiomyopathy have positive family history for this
disease. Physical examination of patients with hypertrophic cardiomyopathy may be completely normal
and on the other hand, athletes with athlete’s heart may have an accidental systolic murmor [3]. In our
patients we found systolic murmur in both hyupertrophic cardiomyopathy cases but the patient with
athlete’s heart had physiologic finding on auscultation. Both our cardiomyopathy patients had also ST
segment changes on electrocardiography associated with deep Q in one of them. Typically, ST segment
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Contribution of MRI to differential diagnosis between hypertrophic cardiomyopathy and...
depression has been described in patients with hypertrophic cardiomyopathy, in contrary to that, our
patients had ST segment elevations [9]. ST segment elevation is a rare finding in hypetrophic
cardiomyopathy patients and it is necessary to rule out myocardial infarction and other causes of ST
elevation, like pericarditis, Brugada syndrome or left bundle branch block [20]. The presence of left frontal
hemiblock is indicative for hypertrophic cardiomyopathy. Surprisingly, we found left frontal hemiblock in
the patient with athlete’s heart. Right bundle branch block, that was present in patient wiht sinus
bradycardia, may also be indicative for athlete’s heart.
The next steps in the diagnostic algorithm are stress tests, Holter monitoring, MRI and genetic
testing [9]. The patient with athlete’s heart had appropriate physiological response to stress and Holter
monitoring showed only significant sleep bradycardia with first degree atrio-ventricular block. Patients
with hypertrophic cardiomyopathy did not have any changes on Holter monitoring.
Echocardiography revealed significant differences, both patients with hypertrophic
cardiomyopathy had interventricular septum thickness of 31 and 22 mm respectively, while the initial
interventricular septum depth in athlete’s heart patient was 12.3 mm with subsequent increase to 14 mm
over 3 years. The last value already entered the „gray zone“ (13 – 15 mm) so MRI was indicated. In
comparison to echocardiography, MRI has several important advantages. The weak points of transthoracic
echocardiography are anterolateral segments of left venticle, papilary muscles and right-sided heart
structures, including recognition of right intraventricular obstruction. The presence of myocardial fibrosis
(positivity of late gadolinium enhancement) is recognised as a risk factor for sudden cardiac death in
patients with hypertrophic cardiomyopathy [12,21,22]. Fibrotic changes are not present in individuals with
athelte’s heart. MRI with gadolinium contrast can detect myoardial fibrosis and is therefore important tool
in the diagnostic process. Majority of patients with cardiomyopathy present myocardial fibrosis on
gadolinium MRI [23]. Both our patients with hypetrophic cardiomyopathy had positive late gadolinium
enhancement on MRI representing myocardial fibrosis. The first patient had an asymmetric
cardiomyopathy type with dominant convexity in the mid-septum spreading to left ventricle. Myocardial
fibrosis in him was present in anteroseptal area. The second patient had more symmetric cardiomyopathy,
also with positive late gadolinium enhancement on MRI. The last patient with athlete’s heart showed no
signs of any morphological changes on MRI. It is important to point-out the significant role of gadolinium
MRI in the differential diagnosis, by its ability to detect fibrotic myocardial changes, which can not be
diagnosed by standard echocardiographic examination. The importance is to some extend limited by the
accessibility to the examination, its cost and time consuption.
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