From the Guidelines
Increased right ventricular pressure, a dilated right ventricle, and normal right ventricular systolic function in a healthy 43-year-old cyclist can indeed cause potential problems and should be evaluated by a cardiologist. These findings suggest possible pulmonary hypertension or right ventricular pressure overload, which is not normal even in athletes 1. While athletes commonly develop some cardiac adaptations (such as left ventricular hypertrophy), right-sided cardiac changes of this nature are not typical physiological adaptations to exercise. The cyclist's RV pressure of 33mmHg is considered borderline elevated, and according to the study by Zamanian et al. 1, a comprehensive workup is warranted to determine the cause of the elevated RV pressure.
Potential Underlying Conditions
The cyclist should undergo comprehensive cardiopulmonary evaluation including:
- Echocardiography
- Cardiac MRI
- Pulmonary function tests
- Possibly right heart catheterization to determine the cause Potential underlying conditions include:
- Pulmonary embolism
- Pulmonary arterial hypertension
- Left heart disease
- Congenital heart defects like atrial septal defect
- Pulmonary disease
Importance of Evaluation
Even with preserved systolic function, chronic right ventricular pressure overload can eventually lead to right heart failure, arrhythmias, and exercise intolerance 1. The study by Gatzoulis et al. 1 highlights the importance of evaluating patients with pulmonary regurgitation and RV dilatation, as they are at risk of developing severe RV dysfunction and ventricular arrhythmias.
Management
The cyclist should temporarily reduce high-intensity training until the evaluation is complete and a management plan is established by a cardiologist with experience in sports cardiology. A comprehensive evaluation and management plan can help prevent potential complications and ensure the cyclist's safety during exercise.
From the Research
Potential Problems with Increased RV Pressure, Dilated RV, and Normal RV Systolic Function
- Increased right ventricular (RV) pressure, a dilated right ventricle (RV), and normal right ventricular (RV) systolic function in a healthy 43-year-old cyclist may cause potential problems, particularly if the RV pressure is significantly elevated, as in this case with a pressure of 33mmHg.
- The studies suggest that elevated pulmonary arterial pressure can lead to right ventricular dilatation and hypertrophy, which can eventually result in right heart failure 2.
- A dilated RV can also lead to tricuspid regurgitation, which can further worsen the condition 3.
- Normal RV systolic function may not necessarily indicate the absence of problems, as the right ventricle may still be under increased stress due to the elevated pressure 4.
- The combination of increased RV pressure and a dilated RV may increase the risk of pulmonary arterial hypertension (PAH), a life-threatening condition characterized by elevated pulmonary arterial pressure 5, 6.
Diagnostic and Prognostic Value of Imaging Modalities
- Cardiac magnetic resonance imaging (MRI) and echocardiography have been shown to have greater diagnostic utility than computed tomography (CT) in assessing patients with suspected PAH 3.
- MRI measurements, such as ventricular mass index (VMI), have been found to have prognostic value in patients with PAH 3.
- Echocardiography can provide useful information on RV function and tricuspid regurgitation, which can help in diagnosing and managing PAH 3, 2.
Treatment Options
- Various treatment options are available for PAH, including endothelin receptor antagonists, phosphodiesterase 5 inhibitors, and prostacyclins 5, 6.
- Bosentan, an endothelin receptor antagonist, has been shown to improve exercise capacity, functional class, and hemodynamics in patients with PAH-associated congenital heart disease 5.
- Newer generation endothelin receptor antagonists, such as ambrisentan and macitentan, may have greater improvements in hemodynamic parameters compared to bosentan 6.