Sport-specific cardiac adaptation in 104 female elite athletes: MRI findings from the ELITE cohort
Authors: Van Hattum J , Van Diepen M A , Van Diepen M A , Verwijs S M , Verwijs S M , Daems J J N , Daems J J N , Boekholdt S M , Boekholdt S M , Van Randen A , Van Randen A , Planken R N , Planken R N , Groenink M , Groenink M , Nederveen A J , Nederveen A J , Moen M H , Moen M H , Wilde A A M , Wilde A A M , Pinto Y M , Pinto Y M , Jorstad H T , Jorstad H T 
Published: November 2023

Abstract

Background
The overlap between exercise-induced cardiac remodelling (EICR) and cardiac pathology is a key challenge in sports cardiology. Mainly based on findings in male athletes, EICR is thought to be sport-specific, and varyingly characterised by increased ventricular volumes, cardiac mass and/or wall thickness. However, no large cardiac magnetic resonance imaging (CMR) study in female elite athletes has extensively examined sport-specific cardiac adaptations.

Purpose
To investigate sport-specific EICR on CMR in a large cohort of female elite athletes.

Methods
We performed a cross-sectional CMR analysis in female elite athletes (Para-/Olympic or professional athletes competing ≥10 hours per week at a national/international level) aged ≥16 years, included in the ELITE cohort (1). We excluded athletes with known cardiovascular disease, and classified athletes according to the ESC sports disciplines classification. Our outcomes of interest were sport-specific EICR, defined as BSA-indexed LV and RV end-diastolic volume (EDVi), LV wall mass (LVMi), and maximal LV wall thickness (LVWdmax), LV remodelling index (LVMi/LVEDVi), and LV/RV ratio (LVEDi/RVEDVi). CMR was performed according to a uniform protocol, preferentially on 1.5T. A dedicated core-lab analysed all CMRs in Circle Cardiovascular Imaging.

Results
We included 104 female elite athletes, 96% Caucasian, mean age of 26.1 ±5 years, BSA 1.8 ±0.1 m2, and mean professional (≥10 hours/week) athlete years of 11.6 ±5. The athletes were classified as skill (n=8), power (n=9), mixed (n=39) and endurance (n=48) sports. Endurance athletes had markedly increased left- and right ventricular volumes compared to power (LVEDVi 111.2 ±15 vs 98.7 ±11 ml/m2, p=0.009; RVEDVi 114.8 ±18 vs 101.7 ±10 ml/m2, p=0.006) and mixed athletes (LVEDVi 111.2 ±15 vs 107.3 ±13 ml/m2, p=0.058; RVEDVi 114.8 ±18 vs 107.8 ±12 ml/m2, p=0.031) (Figure 1). No differences were found between endurance, mixed, power and skill athletes in LVEDVi/RVEDVi ratios (0.97 vs 0.99 vs 0.97 vs 0.99), LVMi (52.6 ±12 vs 46.9 ±10 vs 48.7 ±10 vs 50.4 ±11 g/m2) (Figure 2), LVWdmax (8.1 ±1 vs 7.9 ±1 vs 7.9 ±1 vs 8.9 ±1 mm), LV remodelling index (LVMi/LVEDVi 0.47 vs 0.44 vs 0.49 vs 0.48), LV ejection fraction (56.3 ±4 vs 56.7 ±5 vs 58.2 ±3 vs 57.7 ±3 %), and RV ejection fraction (54.6 ±4 vs 55.7 ±4 vs 55.4 ±3 vs 56.7 ±4).

Conclusion
In female elite athletes, EICR according to sport categories is mainly characterised by balanced increases in ventricular volumes in endurance athletes, but not in increases in left ventricular wall-mass and thickness, even in sport categories with high static demands. Our findings constitute a first step towards the understanding of sport-specific EICR in female elite athletes.Figure 1.Figure 2.