Eur J Echocardiography (2005) 6, 24e30
The feasibility and usefulness of contrast
exercise echocardiography for the assessment of
left ventricular function in master athletes
Marta Rizzo, Maria Concetta Robertina Vono, Loira Toncelli,
Patricia Pec
xagna, Paolo Manetti, Laura Stefani, Giorgio Galanti)
Department of Medical and Surgical Critical Care, Laboratory of Non-Invasive Cardiology, Sports
Medicine Centre, University of Florence, Viale Gian Battista Morgagni, 85, 50134, Florence, Italy
KEYWORDS
Master athletes;
Exercise
echocardiography;
Endocardial border
Abstract Background The number of competitive master athletes (MA, over 40
years) has been rising. Since the incidence of coronary artery disease (CAD) is increasing in this population, cardiovascular pre-participation screening, including
a maximum exercise test, is recommended. In this context the addition of contrast
to echo could be useful because wall thickening and motion are better markers of
myocardial function when the whole endocardial border (EB) is visible.
Objective To evaluate the feasibility and usefulness of rest and exercise contrast
echo for the assessment of LV wall motion in competitive master athletes with suboptimal acoustic windows.
Methods Forty consecutive MA underwent echo and contrast echo both at rest
and during exercise. Contrast-enhanced images were achieved at rest and at peak
exercise after administration of SonoVue (BR1), using apical 4 and 2-chamber views
divided into 6 myocardial segments (MS). The EB resolution for each segment was
graded as: 0 Z not visible, 1 Z barely visible, 2 Z well-delineated.
Results In the baseline at-rest echo 17/40 (45%) patients were graded as score 0,
22/40 (55%) were graded as score 1 and only 1 athlete has reached score 2. In atrest echo contrast 28/40 (70%) athletes have reached score 1 and 12/40 (30%) score
2. Nobody was graded as score 0. At the same time in the baseline peak-exercise
echo 12/40 (30%) athletes were graded as score 0, 24/40 (60%) athletes reached
score 1 and 4/40 (10%) score 2, while using contrast at peak-exercise echo 28/40
(70%) were grated as score 1 and 12/40 (30%) reached score 2.
The differences about the grading of the score between the two groups with and
without contrasts, at rest and at peak exercise, are statistically significant
(p ! 0.001). Considering the whole of the MS analyzed in the majority of the athletic population studied, we can see that at-rest echo, 64/480 MS (13.3%) were
graded as 0, 156/480 MS (32.5%) as 1 and 260/480 MS (54.2%) were graded 2, while
) Corresponding author. Tel.: C39-3294204277; fax: C39-0554279375.
E-mail address: [email protected] (G. Galanti).
1525-2167/$30 ª 2004 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.euje.2004.05.001
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Received 26 September 2003; received in revised form 10 May 2004; accepted 19 May 2004
Contrast exercise echocardiography in sports cardiology
25
in the peak-exercise 96/480 MS (20%) were graded as 0, 235/480 MS (48.9%) as 1
and 209/480 MS (43.5%) were graded 2. On the other hand, using contrast, in atrest echo, 480/480 MS (100%) were graded as 2 while in the peak-exercise echo
460/480 MS (95.9%) were graded as 2 and 20/480 MS (4.1%) as 1. The percentage
of the MS graded as 2 reach almost the whole number of the analyzed MS with a
percentage increment in the at-rest and peak-exercise echo of 85% and 120%,
respectively.
Conclusions Our results show that the use of contrast echo improves the visibility
of the EB in a way that the two groups of competitive athletes show at rest and
after exercise a significant increment of the score 2 compatible with a better visibility of the EB. These results suggest that contrast echo, both at rest and during
exercise, is a better method for EB analysis to understand the behaviour of the wall
motion in subjects with suboptimal acoustic windows, and could be suitable for cardiovascular screening in master athletes.
ª 2004 The European Society of Cardiology. Published by Elsevier Ltd. All rights
reserved.
Background
Methods
Study population
The study group consisted of 40 consecutive male
master athletes (age range: 51e72 years, mean
age: 59 G 8.5) who were referred to our secondlevel Sports Cardiology Center of the University
of Florence for an exercise echocardiogram to obtain eligibility for athletic competitions.
At the moment of the evaluation, all the athletes were undergoing intensive aerobic training
(at least 3 training sessions per week, each one
lasting 90e120 min). They were engaged in different sports: marathon running (21 athletes), cycling
(13 athletes), tennis (4 athletes) and swimming
(2 athletes).
The athletes evaluated had been referred to our
laboratory after a previous evaluation in a firstlevel center for various problems:
- all presented ECG abnormalities
- 10 had borderline hypertension (mean values
150/85)
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Over the past few years the practice of competitive
sports and vigorous physical conditioning programs
has been widely spreading among middle-aged and
elderly subjects. Physical inactivity and a sedentary
lifestyle as well as age are recognized as major risk
factors for the development of CAD.1e3 Conversely,
it has been demonstrated that exercise can help to
reduce cardiovascular risk factors and decrease
the overall incidence of heart disease.4,5 Unfortunately, acute vigorous physical exertion in elderly
people does not protect against exercise-related
death in the presence of underlying cardiovascular
disease. Sudden death often occurs as ‘a bolt from
the blue’ during physical effort in asymptomatic
and apparently healthy elderly subjects, and
more than 80% of these events are due to CAD.6,7
For these reasons, the possibility of screening
CAD in elderly people engaged in highly intensive
training programs is a very important challenge
for sports cardiologists. Thanks to its satisfactory
specificity and sensibility, exercise echocardiography might be a more suitable test than standard
exercise ECG for cardiovascular screening in active
people over 40 years of age.8,9
However, LV regional wall motion evaluation
both at rest and during exercise relies on clear visualization of the entire endocardial border (EB) in
each cross-sectional image. Unfortunately to date,
even after the introduction of tissue harmonic imaging, up to 10% of baseline echo and up to 30% of
exercise echo are suboptimal, due to inadequate
visualization of EB, which occurs more frequently
in the anterior and lateral walls,10 especially in elderly people.
A number of studies have demonstrated the usefulness of administering a contrast agent to enhance
EB and optimize wall motion analysis in patients
with coronary artery disease, both at-rest echo
and during exercise or pharmacological stress
echo.11e16
The feasibility and usefulness of contrast opacification of the left ventricle at rest and during exercise in the context of sports cardiology still has
to be evaluated.
This study was performed to evaluate the feasibility and usefulness of exercise contrast echo for
the assessment of left ventricular wall motion in
MA with poor acoustic windows.
26
- 8 had a trivial aortic regurgitation (evaluated
as 1C at-rest echo)
- 6 had a trivial mitral regurgitation
- 7 had a combined mild aortic and mitral
regurgitation
All of them were selected for contrast echo and
also harmonic imaging was used during baseline rest
and stress echo because of poor acoustic windows.
No particular exclusion criteria were considered. At baseline at-rest echo, no analysis about
wall motion abnormalities were performed since
the aim of the study was an assessment of the utility of the echo contrast to identify the EB at rest
and after exercise even if this may improve the interpretation of wall motion.
Informed consent for the protocol was obtained
from all subjects before their participation.
M. Rizzo et al.
Contrast echo
The contrast agent used in this study was SonoVue
(also referred to as BR1), Bracco, Italy, a secondgeneration ultrasound contrast agent commercially available in Europe, which has outstanding
stability, resistance to pressure and biological
safety.18,19 A 20-gauge intravenous catheter was
inserted into a peripheral vein in the antecubital
fossa, and the contrast agent (SonoVue, 25 mg/
5 ml 0.9 Na Cl) was injected at rest, 1.5 ml in bolus
and 1.5 ml/min with an infusion pump (VueJECTBracco Switzerland) for 3 min; the same method
was used at peak. Each subject received 12 ml of
SonoVue.
All subjects completed the examination without
presenting any early or late side effects linked to
the administration of the contrast agent.
Study design
Image analysis
Stress testing
All the exercise tests were performed on a specifically designed bicycle with a stiff, 45( sloped back,
pliable on the left side, which allowed reduction of
the artifacts due to chest movement and facilitated imaging acquisition during effort. The stress
testing protocol used consisted of progressive increments of 25 W loading every 2 min, starting
from a load of 25 W, up to physical exhaustion.
All the subjects performed a maximum stress
test, reaching 85% or more of the maximal heart
rate estimated for age.
Image acquisition
Both baseline and contrast images were obtained
using a commercially available echo machine
(Megas, ESAOTE Biomedica) equipped with a harmonic scanner.
Studies were performed from an apical window,
using the apical 4 and 2-chamber views, each divided into 6 segments. The mechanical index, during contrast echo image acquisition, was lowered
to 0.7e0.8. The gain was adjusted for each subject
at the beginning of the rest study and kept constant thereafter. The focus was set at the upper
third of the left ventricle to decrease bubble destruction in the near field.
The left ventricle was divided into 6 segments in
both the apical 4-chamber view (basal, mid and
apical interventricular septum and lateral wall)
and the 2-chamber view (basal, mid and apical anterior and inferior wall), for a total of 12 segments
for each subject. Apical 4 and 2-chamber views
were used, according to Standardized Myocardial
Segmentation and Nomenclature for Tomographic
Imaging of the Heart.17
Endocardial border visualization was scored for
each segment using a 3-level-scale:
0 Z border invisible
1 Z barely visible (border visualized only partially throughout a heart cycle and/or
incomplete segment length)
2 Z complete visualization of the endocardial
border
The scores were used to calculate the endocardial border delineation index (EBDI). This was defined as the sum of endocardial scores divided by
12 and was calculated for both the baseline and
the contrast echo imaging.
The images, collected in quad screen format,
were reviewed by 2 experienced blinded readers
who examined the baseline and contrast echo images at different times. If a discrepancy appeared,
a third observer assessed the image and complete
agreement was reached.
Statistical analysis
Statistical analysis was performed using a statistical computer software package for Social Sciences
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All the athletes were submitted to a standard examination followed by myocardial contrast opacification (MCO) both at rest and during exercise test.
Standard and contrast exercise echo were performed with an interval of at least 2 days.
Contrast exercise echocardiography in sports cardiology
for Windows, (released 11.01, SPSS Inc, Chicago,
IL-USA). Data were analyzed using t-Student test
( p ! 0.001) application.
Results
Baseline echocardiography
Out of a total of 480 segments from 40 subjects,
the regional LV endocardial border was not seen
Table 2
Score for each master athlete investigated
Baseline Baseline Contrast Contrast
Score
echo rest echo
rest echo peak
0-1-2
exercise
exercise
for patient
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
18)
19)
20)
21)
22)
23)
24)
25)
26)
27)
28)
29)
30)
31)
32)
33)
34)
35)
36)
37)
38)
39)
40)
0
1
0
1
0
0
1
0
1
0
1
1
1
0
1
0
1
0
1
1
0
1
2
1
1
0
0
0
1
1
0
1
0
1
1
1
1
0
1
0
0
0
1
1
1
1
0
0
1
0
1
0
0
1
1
1
1
0
0
1
1
0
1
1
2
0
1
1
2
1
2
1
1
1
1
2
1
1
2
1
1
2
2
1
1
1
1
1
1
1
1
2
2
1
1
1
2
1
2
1
2
1
2
1
1
1
1
1
2
1
1
1
1
1
2
2
1
1
2
1
1
1
2
2
2
2
2
2
2
1
2
2
1
1
1
2
2
1
2
2
2
2
1
2
2
2
1
1
2
2
2
1
2
1
2
2
1
2
2
2
(score Z 0) in 64/480 (13.3%) segments at rest
examination. 156/480 (32.5%) segments, an average of 3.58 of 12 segments per subject (32.5%),
were not correctly interpretable due to partial
Rest and peak exercise EBD at standard and MC echo
Score
Echo rest
Echo peak ex
MCE rest
MCE peak ex
0
1
2
TOT segments
64 (13.3%)
156 (32.5%)
260 (54.2%)
480
96 (20%)
235 (48.9%)
209 (43.5%)
480
0
0
480 (100%)
480
0
20 (4.1%)
460 (95.9%)
480
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In the baseline at-rest echo 19/40 (47%) MA were
graded as score 0, 22/40 (55%) were graded as score
1 and only 1 athlete had reached score 2. In at-rest
echo contrast 28/40 (70%) athletes have reached
score 1 and 10/40 (25%) score 2. Nobody was graded
as score 0. At the same time in the baseline peakexercise echo 11/40 (27.5%) athletes were graded
as score 0, 24/40 (60%) athletes reached score 1
and 12/40 (30%) score 2, while using contrast at
peak-exercise echo 28/40 (70%) were grated as
score 1 and 12/40 (30%) reached score 2.
The differences about the grading of the score
between the two groups with and without contrast, at rest and at peak exercise, are statistically
significant ( p ! 0.001). Considering the whole of
the MS analyzed in the majority of the athletic
population studied, we can see that at the atrest echo, 64/480 MS (13.3%) were graded as 0,
156/480 MS (32.5%) as 1 and 260/480 MS (54.2%)
were graded 2, while in the peak-exercise 96/480
MS (20%) were graded as 0, 235/480 MS (48.9%) as
1 and 209/480 MS (43.5%) were graded 2. On the
other hand, using contrast, in at-rest echo, 480/
480 MS (100%) were graded as 2 while in the peakexercise echo 460/480 MS (95.9%) were graded as
2 and 20/480 MS (4.1%) as 1 (Table 1).
Table 2 shows the behaviour of the score in each
group of the MA analyzed at rest and at peak exercise with and without contrast.
Table 3 shows the percentage increment of the
identification of the EB in the at-rest and peakexercise echo particularly for score 2 of 85% and
120%, respectively.
The general and echocardiographic data of athletes are presented as mean G SD (Tables 4 and 5).
Table 1
27
28
Table 3
the EB
Score
M. Rizzo et al.
Percentage increment of the visibility of
0
Baseline
13.3
echo rest MS %
Contrast
0
echo rest MS %
Baseline echo
20
peak exercise MS %
Contrast echo
0
peak exercise MS %
1
2
Percentage
increment
32.5 54.2
0
100
85%
48.9 43.5
4.1
95.9 120%
visualization of the border and/or incomplete
segment length (score Z 1); these segments
were generally observed in the anterior or lateral
wall.
After the administration of SonoVue, 100%
of segments were completely visualized at-rest
echo.
At the peak of exercise 96/480 (20%) segments
were not visible and 235/480 (48.9%), an average
of 5.87 of 12 segments per subject, were not
correctly interpretable (score Z 1) at standard
exercise echo.
After the administration of SonoVue at peak exercise, 460 segments could be perfectly visualized
(score = 2) and only 20 segments belonging to the
lateral wall (4.1%) (p ! 0.001 baseline vs. contrast) were scored 1 at peak exercise after administration of the contrast agent (Table 1).
After the administration of SonoVue we failed to
identify any abnormality in wall motion in any of
the evaluated subjects.
The interobserver agreement was 96% using the
3-point scoring system.
Table 4
General data of the athletes
Age ( years)
Heart rate (bpm)
BMI (kg/mq)
BSA (mq)
BPs (mmHg)
BPd (mmHg)
Total cholesterol (mg/dl)
Training per week (h)
59
61
26.7
1.8
140
85
175
6
G
G
G
G
G
G
G
G
8.5
7
2
2
15
5
10
3.8
Legend: BMI, body mass index; BSA, body surface area; Bps,
systolic blood pressure; Bpd, diastolic blood pressure.
Echocardiographic data of athletes
LVIDd (mm)
LVIDs (mm)
LVPWTd (mm)
IVSTd (mm)
LVM ( g)
LVMI ( g/mq)
Parietal stress (dyn/cm2)
EF%
E/A
48
28
9.5
10.1
215
125
65
63
1.1
G
G
G
G
G
G
G
G
G
4.5
2.5
1.3
1.2
23.7
6.9
7
7
0.5
Legend: LVIDd Z left ventricular end diastolic internal
dimension; LVIDs Z left ventricular end systolic internal dimension; LVPWTd Z end diastolic left ventricular posterior
wall thickness; IVSTd Z end diastolic interventricular septum thickness; LVM Z left ventricular mass, LVMI Z left
ventricular mass index; EF% Z ejection fraction; E/A Z EA
ratio.
Discussion and conclusions
The importance of this study lies in two aspects:
1) First, it confirms that i.v. administration of
SonoVue can enhance EB in subjects with poor
acoustic windows, thus optimizing the evaluation of LV wall motion and systolic function,
both at rest and during exercise testing.
2) Secondly, this is the first study evaluating the
feasibility and usefulness of contrast exercise
echocardiography in the setting of Master
Athletes Sports Medicine, and to date, data
regarding the feasibility of exercise contrast
echo have been very limited.20
The results of this study are particularly significant because the number of master athletes is on
the constant, continuous increase throughout the
western world. The American Heart Association
terms master athletes: ‘conditioned, experienced
competitive athletes who continue to compete
after their formal careers end but also [include]
‘‘walk-up’’ competitors, sometimes referred to
as ‘‘weekend warriors’’ with only sporadic training regimens, as well as those who resume competition after long periods of physical inactivity’.21
In fact, as asymptomatic, sedentary individuals
over 40 years old begin (or begin again) an exercise
program, there is a period of increased risk during
which exertion can provoke a cardiac event,
whereas such risk associated with habitual exercise in active individuals is relatively low. Also, it
is generally assumed that particularly strenuous
exertion or sports competition may predispose athletes to greater cardiac risk than non-strenuous
physical activity. An increasing number of sudden
deaths while exercising are reported in master
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Exercise echocardiography
Table 5
Contrast exercise echocardiography in sports cardiology
- possibility of performing the test in an outpatient clinic
- relatively low cost (vs. perfusion scintigraphy)
- shorter time of performance and interpretation of the test (vs. perfusion scintigraphy)
- absence of radiation
The addition of the contrast agent makes the
method specifically indicated for evaluation of
global and segmental LV kinesis and systolic and diastolic function in competitive master athletes
with poor acoustic windows.
Limitations and future application
This feasibility study used a fairly low number of
subjects. The contrast echo must be compared
both with a gold standard id e scintigraphy or coronarography, both of which have a higher cost.
There is no doubt that the MA population is bound
to increase considerably in the future and
therefore, due to the particular nature of this population, a specific cardiovascular evaluation will
become necessary.
Only apical projections were used in this study;
the basal segments may be difficult to evaluate,
since they are parallel to the ultrasound beam.
The addition of the infusion method permits image
stabilisation.
There is another equally, no less important, reason why the contrast echo method can be show
itself to be very useful, i.e., the possibility of using
a contrast agent coupled with new echo image
software, to obtain information on perfusion and
hence on the coronary reserve both at rest and
during stress, and hence the possibility of assessing, with a non-invasive method, the true effects
that the practice of sport has on the population
of elderly athletes.
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