Making Sense of Masters Athletes’ Cardiac Imaging: Expert Review

Physicians caring for older athletes need to be aware of their unique cardiovascular adaptations and risks compared with younger competitors, and while multimodality imaging can help with risk stratification, the results need to be carefully interpreted in light of training-induced cardiac changes, according to a state-of-the-art review.

Masters athletes—those 35 years and older who continue to participate in organized, competitive, or high-volume/high-intensity physical activity—typically show signs of distinctive remodeling, such as pronounced atrial enlargement and ventricular adaptation.

What makes things tricky, say the experts, is that these changes might be shaped by the timing, duration, and type of sport, which might begin in youth or later in life, as well as normal physiological aging and/or the onset of cardiovascular disease.

“It’s similar with almost any patient cared for in the sports cardiology world, but there are certainly nuances in this [older] population,” said senior author Jonathan Kim, MD (Emory University School of Medicine, Atlanta, GA). “Mixed in with that is that cardiorespiratory fitness is indeed cardioprotective, but it doesn’t completely exonerate the development of cardiac risk factors and even the development of cardiac disease.”

The new review was drafted by the American College of Cardiology (ACC) Sports and Exercise Cardiology Council and published in JACC: Cardiovascular Imaging, with lead author Dermot Phelan, MD, PhD (Sanger Heart and Vascular Institute, Charlotte, NC). It highlights the role that imaging can play in caring for these athletes in the context of some of the more common cardiac abnormalities that physicians will encounter in an older athletic population. These might include myocardial fibrosis picked up on cardiac MR or left atrial remodeling that may predispose the group to higher risks of atrial fibrillation, both of which are common in endurance athletes. The review covers not only the commonly seen imaging abnormalities, but also various “red flags” that might require further clinical investigation.

“There’s too many masters athletes out there for only sports cardiologists to take care of,” said Kim. “Preventive cardiologists, [electrophysiologists], and interventionalists, they’re also going to take care of masters athletes, and hopefully this provides a guide.”

Imaging in Light of Athletic History

In asymptomatic masters athletes, the benefits of early disease detection with imaging must be balanced with the risks of overdiagnosis and unnecessary interventions. There are studies showing that masters athletes may have a higher risk of subclinical atherosclerosis, particularly coronary artery calcification (CAC), that results from a lifetime of exercise at high intensities, say the experts. High CAC scores are associated with an increased risk of coronary artery disease, and while clinical guidelines recommend using the metric to help clarify patient risk, the prognostic utility of CAC scoring has not been established in masters athletes.

“If you get imaging or testing done on somebody who is not having symptoms, you always have to be careful about how to interpret [the findings],” said Kim. “When thinking about screening for coronary disease and cardiovascular risk with calcium scoring and things like that, there is a big difference between the masters athlete versus an older person in the general population.”

For general primary prevention, coronary CT angiography is not recommended for asymptomatic masters athletes, but it might be considered in higher-risk people with multiple risk factors or a family history of early disease.  

Among symptomatic older athletes, such as those with angina symptoms, doctors should follow contemporary US or European guidelines for managing chest pain. Coronary CT angiography “plays a pivotal role” for evaluation when there is worry about coronary artery disease, say the experts.

The reviewers also provide cardiovascular imaging considerations for masters athletes with exercise intolerance.

“One of the things that we wanted to touch on is sometimes masters athletes come in with varied nonspecific symptoms,” said Kim. “They don’t necessarily come in with the chest tightness running up a hill or running up the stairs. They may just come in with this perceived exercise intolerance: ‘Doc, I am not as fast, my splits are a minute-and-half slower than they were 3 months ago. Something’s going on.’ It doesn’t always mean they have coronary disease or atrial fibrillation, but if you take care of this population, you need to understand that just because they’re still running relatively fast miles, that doesn’t exclude the possibility that there’s something going on.”

To TCTMD, Kim said this is a unique time in sports cardiology as there are updated clinical reference documents, such as the scientific statement on clinical considerations for competitive sports for athletes with heart conditions from the ACC and the American Heart Association. This review on multimodality imaging aims to help doctors care for their athletic patients and to provide some “rules of thumb and key points” to consider. In this patient context, the goal is optimized cardiovascular care that supports safe, lifelong participation in sports and/or exercise, say the experts.

Just because they’re still running relatively fast miles, that doesn’t exclude the possibility that there’s something going on. Jonathan Kim

Claudio Gil Araújo, MD, PhD (CLINIMEX, Rio de Janeiro, Brazil), who wasn’t involved in the study but has investigated the clinical benefits of exercise and physical fitness, praised the new review and noted that “masters athletes” encompass a large group of people. For this reason, the term itself might be imprecise or misleading, he said.

“Nowadays, in various sports modalities, athletes continue their career over the fifth and even the sixth decades of life,” he told TCTMD via email.

For this reason, there are even nuances to interpreting findings depending on the patient. For example, some masters athletes might have continued training and competing from childhood while others may have become active starting in middle age. Others might participate in sports without a large strength or endurance component where major cardiac adaptations wouldn’t be expected.

Araújo said the “the best chance to evaluate the clinical relevance of a functional or imaging finding is when you have the opportunity to compare the current with previous results from the same individual.” Possible abnormal results kept for years are likely irrelevant, while even minimal changes from normal to mildly abnormal or from mildly to frankly abnormal are very informative. He added that it’s always worth emphasizing that people with high levels of aerobic fitness tend to live much longer than those who are sedentary or less active or fit.