The Role of Imaging

In athletes of all age groups, the appropriate application of advanced imaging techniques is crucial to detect, graduate and potentially treat cardiovascular conditions that may pose an increased risk for continued sports participation. This primarily refers to the prevention of acute cardiac events such as sudden cardiac death, but also involves the identification of both negative and positive effects on the development and the clinical course of chronic cardiac disorders. This is of particular relevance in recreational/master athletes, since these individuals very often perform strenuous activities such as marathon or triathlon in a non-organized and non-supervised fashion. In addition, recreational/master athletes are usually at least middle-aged and have very often been exposed to elevated cardiovascular risk factor profiles over a longer period of time as compared to young competitive athletes. By means of echocardiography, for example, a common clinical scenario is to differentiate between increased left ventricular wall thickness induced by either long-term intensive exercise training or by hypertension. Coronary computed tomography contributes to advanced risk stratification and to the detection of coronary artery disease as the main cause of SCD in this cohort; this also holds true for exercise echocardiography, nuclear imaging and cardiac magnetic resonance imaging. The latter also identifies regions of myocardial fibrosis that may indicate an increased risk for arrhythmias, either by late gadolinium enhancement or by T1 mapping. Invasive coronary angiography, if indicated according to symptoms or suggestive findings during non-invasive procedures, either confirms or excludes relevant coronary stenosis and allows immediate interventional treatment. Advanced intracoronary artery imaging including intravascular ultrasound or assessment of fractional flow reserve can help to graduate the severity of stenoses and to understand epicardial and intramyocardial microvascular causes of symptoms. However, the need of radiation exposure and contrast agents as well as cost issues require careful risk-benefit assessment, especially in asymptomatic athletes with risk factors.