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American Society of EchocardiographyCardiology2020advanced

Use of Multimodality Cardiovascular Imaging in Young Adult Competitive Athletes

Published by American Society of Echocardiography

31Recommendations
170References
4Tables
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Summary

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This guideline provides a comprehensive framework for using multimodality cardiovascular imaging (TTE, CMR, CTA) to evaluate competitive athletes. It outlines how to differentiate physiological exercise-induced cardiac remodeling from pathologic cardiomyopathies and details the appropriate clinical scenarios for incorporating diagnostic imaging following pre-participation screening or symptom presentation.

sports cardiologyASE2020guidelinesmultimodality imagingtransthoracic echocardiographycardiac MRICT angiography

Key Takeaways

  • 1
    Multimodality imaging (TTE, CMR, CTA) plays a fundamental role in evaluating competitive athletes to differentiate physiologic exercise-induced cardiac remodeling (EICR) from underlying cardiovascular disease.
  • 2
    Transthoracic echocardiography (TTE) is the accessible, cost-effective, first-line imaging modality for evaluating competitive athletes presenting with symptoms or abnormal screening findings.
  • 3
    Cardiac magnetic resonance (CMR) is the preferred second-line modality for clarifying ambiguous TTE findings, providing detailed characterization of right ventricular morphology, apical hypertrabeculation, and myocardial tissue composition (fibrosis/edema).
  • 4
    Routine use of noninvasive imaging is not recommended as a universal first-line screening tool during pre-participation cardiovascular screening (PPCS) in asymptomatic athletes.
  • 5
    EICR differs based on the physiologic demands of the sport (isotonic vs. isometric), sex, ethnicity, and genetic factors, and clinicians must integrate these variables to interpret structural measurements accurately.

Key Recommendations

Pre-participation Cardiovascular Screening

  • rec_1

    The use of noninvasive imaging including comprehensive and limited TTE, CTA, and CMR is not recommended as a first-line strategy during PPCS.

    Screening

Differentiating EICR from Pathology - Left Ventricular Wall Thickening

  • rec_2

    LV wall thickening of unclear etiology or incomplete visualization of all LV wall segments during TTE should prompt additional imaging with CMR.

    Diagnosis

Differentiating EICR from Pathology - Right Ventricular Dilation

  • rec_3

    TTE has important limitations with respect to delineating the magnitude and etiology of RV dilation in CA. CMR should be performed in all CA with RV dilation of unclear etiology.

    Diagnosis

The Symptomatic Competitive Athlete - Exertional Chest Discomfort

  • rec_4

    TTE should be performed as the initial noninvasive imaging test in CA presenting with possible or probable cardiac chest pain.

    Diagnosis

The Symptomatic Competitive Athlete - Syncope

  • rec_5

    CA presenting with syncope of unclear etiology, particularly syncope during exercise, should undergo comprehensive multimodality imaging beginning with TTE and extending, on a case-by-case basis, to CTA or CMR to exclude structural and valvular heart disease.

    Diagnosis

Exercise-Induced Cardiac Remodeling (EICR) - Aortic Adaptations

  • rec_6

    Mild aortic sinus or ascending aortic dilation may occur in young CA but absolute aortic measurements of ≥40 mm (men) and ≥34 mm (women) are uncommon. A finding of aortic sinus or ascending aortic dimensions in excess of these sex-specific cut-points should prompt clinical consideration of aortic pathology and subsequent imaging with either gated CTA or CMR.

    Diagnosis

Scope & Objectives

Clinical Topic

Sports Cardiology

Objectives

To provide clinical imaging specialists with a comprehensive guide for the performance of multimodality imaging in competitive athletes.

Target Patient Population

Young adult competitive athletes (age range beginning with the cessation of puberty and ending at age 35)

Diagnostic Criteria

Clinical cut-offs are provided to differentiate physiological from pathological findings, such as left ventricular wall thickening up to 13-15 mm depending on ethnicity, and upper limits for aortic root dimensions.

Target Providers

Clinical imaging specialistsCardiologistsSports medicine physicians

Patient Criteria & Setting

Therapeutic Area

Cardiovascular Disease

Guideline Scope

DiagnosisScreening

Inclusion Criteria

  • Competitive athletes

Care Settings

OutpatientEchocardiography laboratory

Special Populations

Pediatric competitive athletesMasters level competitive athletesAthletes with congenital heart disease

Safety & Contraindications

Monitoring Guidance

Athletes with confirmed congenital heart disease should undergo functional assessment, shared decision-making, and close clinical surveillance.

Authors & Contributors

Aaron L. BaggishRobert W. BattleTimothy A. BeaverWilliam L. BorderPamela S. DouglasChristopher M. KramerMatthew W. MartinezJennifer H. MercandettiDermot PhelanTamanna K. SinghRory B. WeinerEric Williamson

Guideline Features

Flowcharts includedMultidisciplinary

Learning Context

Difficulty

advanced

Exam Relevance

Cardiology Board ExamsNational Board of Echocardiography (NBE) ExamsSports Medicine Certification

Learning Paths

Sports CardiologyMultimodality ImagingEchocardiographyCardiac Magnetic ResonanceExercise-Induced Cardiac RemodelingPre-participation ScreeningAthlete's Heart