CORRESPONDENCE: LETTER TO THE EDITOR
Physiological Upper Limits of Left Atrial Diameter in Highly Trained Adolescent Athletes
Sandeep Basavarajaiah, MRCP,
Jayesh Makan, MRCP,
S.H. Reza Naghavi, MD,
Greg Whyte, PhD,
Sabiha Gati, MBBS and
Sanjay Sharma, BSc, FRCP, MD*
* Department of Cardiology, University Hospital of Lewisham, Lewisham High Street, London SE13 6LH, United Kingdom (Email: ssharma21{at}hotmail.com).
We have read the study by Pelliccia et al. (1) in which the investigators characterized the prevalence and upper limits of left atrial (LA) enlargement in highly trained adult athletes. The data are of great interest and provide yet another parameter for aiding the differentiation of physiological adaptation (athlete’s heart) from hypertrophic or dilated cardiomyopathy, which are recognized causes of sudden death in athletes. Currently, there are few data on structural cardiac changes in adolescent athletes in whom deaths from cardiomyopathy are more prevalent than in adults (2). Data derived from adult athletes cannot be extrapolated to younger athletes for the purposes of differentiating athlete’s heart from cardiomyopathy. This is because adolescent athletes are physically less mature and have trained for a shorter duration than have adult athletes.
The death of some high-profile athletes has put pressure on sporting organizations in the United Kingdom to implement screening of apprentice athletes (usually aged 14 to 18 years) before recruitment for competition (3). Our establishment performs cardiovascular evaluation in junior athletes (aged 14 to 18 years) from the British Lawn Tennis Association, premier soccer and rugby league junior squads, and the national cycling, swimming, boxing, and triathlon squads. Between 2002 and 2005 we evaluated 1,000 highly trained adolescent athletes (75% male; mean body surface area 1.75 ± 0.16 m–2) using echocardiography. Cardiac measurements and Doppler indices were measured by conventional methods.
Adolescent athletes had a mean LA diameter of 31 ± 4.8 mm. Based on upper limits derived from an age-, gender-, and size-matched sedentary control group, 120 (12%) athletes had a greater than predicted LA diameter. Although, 368 athletes had left ventricular wall thickness (4) or cavity dimension (5) measurements exceeding predicted upper limits and consistent with that seen in patients with morphologically mild hypertrophic or dilated cardiomyopathy, respectively, none of the athletes had a left atrial diameter >45 mm. We considered all athletes with enlarged cardiac dimensions to have physiological cardiac enlargement based on the absence of symptoms or family history of cardiomyopathy and the presence of normal indices of diastolic and systolic function.
Our observations suggest that in highly trained adolescent athletes, LA diameter is modestly increased; however, a diameter >45 mm is exceedingly rare. We conclude that, during assessment of adolescent athletes, LA diameter measurement >45 mm should be applied as a cut-off point in differentiating physiological enlargement from cardiomyopathy in an adolescent athlete with a wall thickness or cavity size exceeding upper limit. This figure is considerably less (5 mm; 11%) than that recommended for adult athletes from the study by Pelliccia et al. (1).
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1. Pelliccia A, Maron BJ, Di Paolo FM, et al. Prevalence and clinical significance of left atrial remodeling in competitive athletes J Am Coll Cardiol 2005;46:690-696.[Abstract/Free Full Text]2. Maron BJ, Shirani J, Poliac I, Mathenge R, Roberts W, Mueller F. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles JAMA 1996;276:199-204.[Abstract/Free Full Text] 3. Maron BJ. How should we screen competitive athletes for cardiovascular disease? Editorial Eur Heart J 2005;26:428-429.[Free Full Text] 4. Sharma S, Maron BJ, Whyte G, Firoozi S, Elliott PM, McKenna WJ. Physiologic limits of left ventricular hypertrophy in elite junior athletesrelevance to differential diagnosis of athlete’s heart and hypertrophic cardiomyopathy. J Am Coll Cardiol 2002;40:1431-1436.[Abstract/Free Full Text] 5. Makan J, Sharma S, Firoozi S, Whyte G, Jackson PG, McKenna WJ. Physiological upper limits of left ventricular cavity size in highly trained adolescent athletes Heart 2005;91:495-499.[Abstract/Free Full Text]
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