What is the management plan for an athlete with left ventricular hypertrophy (LVH) on electrocardiogram (EKG) during a sports physical?

Management of Athletes with Left Ventricular Hypertrophy on EKG

When an athlete presents with left ventricular hypertrophy (LVH) on electrocardiogram during a sports physical, a comprehensive cardiovascular evaluation is necessary to distinguish between physiological athletic adaptation and pathological hypertrophy that may increase risk of sudden cardiac death.

Initial Assessment

1. Evaluate ECG characteristics beyond voltage criteria:

   • Isolated QRS voltage criteria for LVH is common in athletes and generally benign 1
   • Warning signs requiring further evaluation:
     • Non-voltage criteria for LVH (left atrial enlargement, left-axis deviation, ST-segment depression, T-wave inversions, pathological Q-waves) 1
     • T-wave inversions in inferior and/or lateral leads 1
     • ST-segment depression (rare in athletes) 1

2. Clinical assessment:

   • Family history of sudden cardiac death or hypertrophic cardiomyopathy (HCM)
   • Symptoms (syncope, chest pain, palpitations, dyspnea)
   • Blood pressure measurement to exclude hypertension 1

Diagnostic Algorithm

Step 1: Echocardiography

Echocardiography is mandatory for all athletes with LVH on ECG with non-voltage criteria 1. Key parameters to assess:

• LV wall thickness measurements:

  • Normal physiological LVH: typically <13 mm in white males, <12 mm in white females, <16 mm in black males, <13 mm in black females 1
  • Gray zone (13-16 mm): requires careful differentiation 1

• LV cavity size and geometry:

  • Athletes typically show enlarged LV cavity (>54 mm) 1
  • Physiological LVH shows homogeneous distribution with <2 mm difference between segments 1
  • Pathological HCM often shows asymmetric or heterogeneous pattern 1

• Diastolic function:

  • Abnormal parameters suggesting pathology: septal e' velocity <8.0 cm/s, E/A ratio <1.0 1
  • TDI parameters: septal E' <12 cm/s and lateral E' <12 cm/s suggest HCM 1

Step 2: Additional Testing (if echocardiogram is inconclusive)

• Cardiac MRI: To detect late gadolinium enhancement (fibrosis) suggestive of HCM 1

• Exercise testing: To assess:

  • Blood pressure response
  • Exercise-induced symptoms
  • ECG changes during exercise
  • Systolic function response to exercise 1

• Detraining period:

  • Consider 3-month detraining period in borderline cases
  • Physiological LVH typically shows regression with detraining 1

Management Recommendations

1. Physiological LVH (Athlete's Heart):

   • Normal LV cavity size with proportionate wall thickness
   • Normal diastolic function
   • Absence of concerning symptoms or family history
   • Recommendation: Allow full participation in all competitive sports with annual follow-up 1

2. Pathological LVH (HCM or other cardiomyopathies):

   • Asymmetric LVH
   • Abnormal diastolic function
   • Positive family history or genetic testing
   • Recommendation: Restrict from competitive sports, with possible exception of low-intensity class IA sports 1

3. Hypertensive LVH:

   • If associated with stage 1 hypertension without target-organ damage: Allow participation with proper BP control and monitoring every 2-4 months 1
   • If associated with stage 2 hypertension: Restrict participation until BP is normalized with appropriate therapy 1

4. Gray Zone Cases (13-16 mm LV wall thickness):

   • Use the criteria in Table 7 from 1 to differentiate athlete's heart from HCM
   • Consider detraining effect, cardiac MRI, and family screening

Follow-up Recommendations

• Athletes with physiological LVH should undergo annual cardiovascular evaluation
• Athletes with repolarization abnormalities, even without structural disease, should have regular imaging follow-up (typically annual echocardiography) 1
• Athletes with hypertensive LVH need regular BP monitoring and medication adjustment as needed 1

Common Pitfalls to Avoid

• Relying solely on voltage criteria for diagnosis of pathological LVH
• Failing to consider ethnicity and sport type in interpretation (endurance athletes and black athletes typically have more pronounced LVH)
• Missing non-voltage ECG criteria that may indicate pathology
• Not considering hypertension as a cause of LVH in athletes

By following this structured approach, clinicians can effectively differentiate between physiological and pathological LVH in athletes, ensuring appropriate sports participation recommendations to minimize risk while maximizing athletic opportunities.