Body surface area, physiologic remodeling may affect cardiac findings in WNBA athletes

Yasmeen Taha, MD

There is a huge gap in data representing women athletes compared to men, and because women are increasingly participating in competitive sports, there is necessity to conduct research that focuses on the female athlete heart. The ultimate goal of sports cardiology research is to differentiate physiological adaptation of exercise from underlying cardiac pathology and to prevent sudden cardiac death in athletes. Another potential for CV research in this area is to detect long-term effects of strenuous exercise on the heart and if those effects are reversible or preventable.

In this study, Shames and colleagues focus on analyzing the echocardiographic criteria of female basketball players’ hearts with a special interest in LV mass index and geometry changes. It is important to define normal LV geometry from abnormal geometry changes in athletes per se, since current values recommended by the American Society of Echocardiography represent data from the “normal” population.

The researchers found that about a quarter of their cohort met the criteria for concentric remodeling and concentric hypertrophy, and 11% had eccentric hypertrophy when indexed to body surface area. This cohort of athletes had higher than average body surface area compared with the normal population. Also, the authors reported no racial differences with regards to LV remodeling.

Their findings drive many questions when it comes to women athletes and their hearts. First, do we need new echocardiographic cutoff values for female athletes in competitive sports? This question can be answered through larger-scale studies including different sports types (static, dynamic and mixed) with larger sample sizes of female athletes and comparing them with otherwise similar nonathlete reference groups. Second, what are other causes or factors that may contribute to this cardiac remodeling such as high BP in athletes? We recently published data (Rambarat C, et al. J Am Coll Cardiol. 2020;doi: 10.1016/S0735-1097(20)30560-X) on 329 female athletes from two Division I NCAA programs. Almost half had higher than average BP during pre-participation evaluation, and systolic BP also correlated with body surface area.

Another interesting finding reported by Shames and colleagues is RV enlargement observed in approximately 40% of WNBA athletes. RV enlargement was also observed in a subset of Italian Olympic athletes in a previous study (D’Ascenzi F, et al. JACC Cardiovasc Imaging. 2016;doi:10.1016/j.jcmg.2016.03.017.) that included both male and female Olympic athletes, however body surface areas of Italian Olympic female athletes were smaller compared with athletes in WNBA.

A previous study (La Gerche A, et al. Eur Heart J. 2011;doi:10.1093/eurheartj/ehr397.) suggested that the right ventricle may be more susceptible to prolonged intense exercise. Areas of myocardial fibrosis were detected by cardiac MRI with late gadolinium enhancement. These changes can be irreversible and may precipitate ventricular arrhythmias and sudden cardiac death.

Racial and ethnic considerations, and indexing to body surface area are important to detect early pathologic RV remodeling in these athletes.

Pre-participation echocardiography should be mandated for all female athletes participating in high-level competitive sports with special focus on LV mass and geometry, atrial size and RV measurements indexed to body surface area. This would provide a huge dataset for female athletes from different racial/ethnic backgrounds. Regular interval follow-up echocardiography would also help in detecting early changes in cardiac dimensions, as well as correlating these findings with other characteristics like BP. This will help to improve identification of women athletes at risk of pathological exercise-induced LV hypertrophy or pathological RV remodeling who may be in the overlap zone between physiologic and pathologic changes and can be further evaluated by other modalities as cardiac MRI or nuclear imaging.

As mentioned above, researchers in sports cardiology need to provide more attention to female athletes. Research with focus on ECG and echocardiographic features of competitive female athletes must increase with studies of other co-factors that may affect female athletes’ hearts as well (eg, BP, hormonal and dietary changes, use of anabolic steroids, intensity/duration of training, etc.).

The “athletic heart” is generally believed to be a benign condition; structural and functional changes in athletes’ hearts in response to increased myocardial demands are usually reversible. However, it is now proposed that some irreversible myocardial damage may occur after prolonged endurance exercise and contribute to arrhythmias or perhaps even myocardial damage, which require close follow-up and early intervention.