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Review
. 2023 Dec 14;12(24):7678.
doi: 10.3390/jcm12247678.

Exercise Stress Echocardiography in Athletes: Applications, Methodology, and Challenges

Stefano Palermi  1 , Simona Sperlongano  2 , Giulia Elena Mandoli  3 , Maria Concetta Pastore  3 , Matteo Lisi  3 , Giovanni Benfari  4 , Federica Ilardi  5 , Alessandro Malagoli  6 , Vincenzo Russo  2 , Quirino Ciampi  7 , Matteo Cameli  3 , Antonello D'Andrea  8 ; Echocardiography Working Group of the Italian Society of Cardiology (SIC)
Affiliations
Review

Exercise Stress Echocardiography in Athletes: Applications, Methodology, and Challenges

Stefano Palermi et al. J Clin Med. .

Abstract

This comprehensive review explores the role of exercise stress echocardiography (ESE) in assessing cardiovascular health in athletes. Athletes often exhibit cardiovascular adaptations because of rigorous physical training, making the differentiation between physiological changes and potential pathological conditions challenging. ESE is a crucial diagnostic tool, offering detailed insights into an athlete's cardiac function, reserve, and possible arrhythmias. This review highlights the methodology of ESE, emphasizing its significance in detecting exercise-induced anomalies and its application in distinguishing between athlete's heart and other cardiovascular diseases. Recent advancements, such as LV global longitudinal strain (GLS) and myocardial work (MW), are introduced as innovative tools for the early detection of latent cardiac dysfunctions. However, the use of ESE also subsumes limitations and possible pitfalls, particularly in interpretation and potential false results, as explained in this article.

Keywords: athletes; athlete’s heart; exercise stress echocardiography; sports cardiology.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
The step-by-step approach to diagnosing athlete’s heart [2]. ECG: electrocardiography; CV: cardiovascular; EST: exercise stress test; CPET: cardiopulmonary exercise test; ESE: exercise stress echocardiography; CMR: cardiac magnetic resonance; CCT: computed coronary tomography; SPECT: single photon emission computed tomography; PET: positron emission tomography.
Figure 2
Figure 2
Exercise stress echocardiography in a 51-year-old master athlete, symptomatic for dyspnea during effort and with a family history of hypertrophic cardiomyopathy with a suspicious left ventricular hypertrophy; during effort, is it possible to observe an increase in mitral regurgitation and a significant left ventricle outflow tract obstruction that could explain the dyspnea. LVOTG: left ventricle outflow tract gradient.
Figure 3
Figure 3
Exercise stress echocardiography in an endurance athlete: note the normal increase in tricuspid annular plane systolic excursion (TAPSE) and the mild increase in B-lines at peak effort. TAPSE: tricuspid annular plane systolic excursion.
Figure 4
Figure 4
ESE protocol and parameters can be assessed at each stage [28]. Blood pressure, ECG recording, and clinical condition monitoring are continuously assessed. LV: left ventricle; LVOT: LV outflow tract; MR: mitral regurgitation; E/e’: ratio of early transmitral diastolic velocity to early TDI velocity of the mitral annulus; RWM: regional wall motion; RV: right ventricle; sPAP: systolic pulmonary artery pressure; W: watt; BPM: beats per minute.
Figure 5
Figure 5
Exercise stress echocardiography in an endurance athlete; the global and regional left ventricular function was within normal limits at rest and during effort, with a normal increase in coronary flow and normal coronary flow reserve (>2). CFVR: coronary flow vascular reserve.
See this image and copyright information in PMC

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