Author + information
- Axel Pressler, MD∗ ()
- ↵∗Department of Prevention, Rehabilitation and Sports Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Strasse 22, 81675 Munich, Germany
I read with great interest the study by Finocchiaro et al. (1), which evaluated left ventricular (LV) geometry in a considerable number of athletes with a particular focus on adaptations to different types of exercise (static, mixed, dynamic) in female athletes versus male athletes. The investigators observed a normal LV geometry in most of the athletes, but particularly among subgroups that performed dynamic exercise, a significantly higher proportion of female athletes exhibited eccentric hypertrophy, whereas male athletes predominantly developed concentric adaptations. The investigators concluded that a pattern of concentric hypertrophy in female athletes who perform dynamic sports represents a rare finding that may raise the suspicion of underlying pathologies in single cases.
In recent years, both scientific and clinical interest in imaging of athlete hearts has increasingly shifted toward the implementation of modern techniques, such as cardiac magnetic resonance or novel echocardiography techniques, into the diagnostic pathways of pre-participation screening (2). In light of this ongoing development, the study by Finocchiaro et al. (1) virtually represents a step backward to a more traditional approach. However, it should be emphasized that we have already accumulated a wealth of data on classic echocardiographic parameters in female athletes. For example, as acknowledged in the discussion, Pelliccia et al. (3) evaluated 600 female athletes in a single study compared with only 439 female athletes in the current study. Considering this, the most important novel aspect of the current study is the calculation of LV geometry by using the combination of relative wall thickness (WT) and left ventricular mass (LVM).
Interestingly, female athletes demonstrated lower LV end-diastolic diameters (LVEDDs) in absolute terms, but when correcting for body surface area (BSA), dimensions turned out to be higher compared with their male counterparts. Recognizing this, the investigators underlined in their limitations the significance of scaling cardiac dimensions to other, potentially more appropriate parameters of body composition, including allometric approaches. The latter take into account the different geometric dimensions of body size variables, challenging the concept of scaling 1-dimensional variables such as LVEDD to 2- or 3-dimensional parameters such as body surface area or fat-free mass (FFM) in a simple, linear fashion.
In this regard, our group published a similar study on 1,051 competitive athletes several years ago, in which we demonstrated that scaling to body size using geometrically adjusted variables enabled a much better understanding of the adaptation of athlete hearts to different types of exercise (4). In this study, we also included a substantial number of Caucasian female athletes (n = 271; >18 years of age); we compared them not only with male athletes but also to age-matched control subjects. The same classification regarding the proportion of dynamic exercise was applied, with even more female athletes included in the dynamic group (n = 153) than in the current study (n = 131). Similarly, no female athlete exceeded a maximal WT of 12 mm, only 1.6% had LVEDDs of >54 mm, 5.2% exceeded a relative WT of 0.42, and no female athlete showed a LVM >145 g/m2. Absolute cardiac dimensions were comparable to the current analysis, and scaling LVEDD to BSA also resulted in greater values in female athletes versus male athletes, but when allometrically scaling to BSA0.5, female athletes again demonstrated lower values. Scaling LVEDD to height2.7 consistently eliminated differences between types of exercise, and sex differences disappeared when scaling LVEDD to FFM0.33 and WT to BSA. Only LVM was consistently greater in both male and female athletes performing dynamic disciplines, and we demonstrated, on a mathematical basis in both genders, that adaptation of LVM to exercise apparently exceeded the sole influence of concomitant changes in body composition. We finally provided reference values for cardiac dimensions scaled to various body size parameters, which aid in clarifying borderline findings in female athletes detected during pre-participation screening.
I agree with the investigators that, particularly in female athletes, a better understanding of cardiac adaptations is still needed. However, adaptation to intensive exercise does not only affect the heart, but body composition as well, and we thus recommend appropriate scaling to body size in case of borderline findings before proceeding to potentially equivocal further investigations.
Please note: Dr. Pressler has reported that he has no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
- Finocchiaro G.,
- Dhut H.,
- D'Silva A.,
- et al.
- La Gerche A.,
- Baggish A.L.,
- Knuuti J.,
- et al.