Myocardial Fibrosis in Competitive Triathletes Detected by Contrast-Enhanced CMR Correlates With Exercise-Induced Hypertension and Competition History

Abstract

Objectives: This study analyzed the presence of myocardial fibrosis detected by late gadolinium-enhancement (LGE) cardiac magnetic resonance (CMR) in correlation with the performance of competitive triathletes objectified by an exercise test and individual competition history.

Background: Myocardial fibrosis detected by LGE CMR has been reported to occur in 0% to 50% of asymptomatic athletes. However, the cause and mechanisms of myocardial fibrosis are unclear.

Methods: Eighty-three asymptomatic triathletes undergoing >10 training h per week (43 ± 10 years of age; 65% male) and 36 sedentary controls were studied by using LGE and extracellular volume (ECV) CMR. Parameters of physical fitness were measured by spiroergometry. Triathletes reported their lifetime competition results.

Results: LGE CMR revealed focal nonischemic myocardial fibrosis in 9 of 54 (17%) male triathletes (LGE⁺) but in none of the female triathletes (p < 0.05). LGE⁺ triathletes had higher peak exercise systolic blood pressure (213 ± 24 mm Hg) than LGE^- triathletes (194 ± 26 mm Hg; p < 0.05). Furthermore, left ventricular mass index was higher in LGE⁺ triathletes (93 ± 7 g/m²) than in LGE^- triathletes (84 ± 11 g/m²; p < 0.05). ECV in LGE^- myocardium was higher in LGE⁺ triathletes (26.3 ± 1.8%) than in LGE^- triathletes (24.4 ± 2.2%; p < 0.05). LGE⁺ triathletes completed longer cumulative distances in swimming and cycling races and participated more often in middle and Iron Man distances than LGE^- triathletes. A cycling race distance of >1,880 km completed during competition had the highest accuracy to predict LGE, with an area under the curve value of 0.876 (p < 0.0001), resulting in high sensitivity (89%) and specificity (79%). Multivariate analysis identified peak exercise systolic blood pressure (p < 0.05) and the swimming race distance (p < 0.01) as independent predictors of LGE presence.

Conclusions: Myocardial fibrosis in asymptomatic triathletes seems to be associated with exercise-induced hypertension and the race distances. There appears to be a safe upper limit, beyond which exercise may result in myocardial fibrosis.

Keywords: LV hypertrophy; T1 and T2 mapping; athletes heart; cardiac MR; extracellular volume; late gadolinium enhancement; myocardial fibrosis.