Tell me the name of your sport and I will tell you the size of your aorta

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Invited editorial
Tell me the name of your sport and
I will tell you the size of your aorta
Xavier Galloo
1
and Bernard Cosyns
1,2
Introduction
During the past few decades, the ‘athlete’s heart’ has
become a matter of contention. The Swedish physician
S Henschen, who diagnosed cross-country skiers with
cardiac enlargement due to both cardiac dilatation and
hypertrophy, using only cardiac auscultation and per-
cussion to estimate heart size, first described it in 1899.
1
Pre-participation cardiac screening may be war-
ranted in athletes, as the number one cause of sudden
death remains cardiovascular death (35% of all sudden
deaths in athletes). In 6.4% of sudden cardiac deaths in
young athletes, aortic dissection is the confirmed
aetiology.
2
Aorta size and different types of sport
The aorta experiences significant haemodynamic stress
during exercise training, leading to variable aortic
remodelling and aortic root enlargement. Current rec-
ommendations for aortic evaluation in athletes are
based upon cut-offs derived from the general popula-
tion. However, there is limited information regarding
the upper physiological limits of the aortic root in ath-
letes. Different studies have already demonstrated that
the aortic root dimensions in (elite) athletes are within
the established limits for the general population.
3,4
As
proposed by Pelliccia et al., an aortic root diameter of
40 mm and 34 mm in males and females, respectively,
can be considered as the upper limits of physiologic
aortic root remodelling.
5
Different sports are associated with a varying work-
load on the heart or stress on the vascular system.
Nowadays, sport disciplines are schematically classified
into four groups according to their isometric and
isotonic characterization (Figure 1).
6
Previous studies
regarding the effect of the type of sport on aorta remo-
delling have led to conflicting results. On the one hand,
data suggest that subjects involved in isotonic exercise
with a high dynamic component (endurance disciplines)
are associated with significant increased aortic dimen-
sions compared with subjects involved in isometric
exercise (strength disciplines), where only trivial
impact was found.
3,7
On the other hand, data from
a different population suggest that strength athletes
have higher aortic root diameters than endurance
athletes.
4
Current echocardiographic recommendations sug-
gest the use of 2D-echocardiography to quantify the
inner-to-inner edge for the aortic annulus and the lead-
ing-to-leading edge (at end-diastole) convention for all
other aortic root measurements rather than M-mode
assessment, where an estimation error of 2 mm may
occur.
8
Cardiac magnetic resonance (CMR) has gained
important accessibility in the work-up of aortic root
quantification. CMR guidelines recommend aortic
root evaluation by the end-diastolic cusp-commissure
distance as the average of three and they should be
made in the diastolic sinus plane of cine acquisition
(as this plane allows all three sinuses to be visualized).
These recommendations are based on favourable
R
2
-values concerning age and body-surface-area
(BSA). Moreover, these values show more closeness
of agreement with the reference echocardiographic
aortic root measurements.
9
Scale or not to scale
In healthy non-athletic subjects, various determinants
have an impact on aortic dimension: height, BSA, age,
sex and blood pressure. Anthropometric variables tend
to have the greatest impact, yet current nomograms
used for the general population did not include suffi-
cient healthy subjects whose height exceeds the 95th
percentile. Reed et al. have demonstrated that the rela-
tionship between aortic root dimension and anthropo-
metric measures is non-linear when body size exceeds
the 95th percentile for height. Also, the aortic root size
tends to plateau with increasing BSA in subjects above
the 95th percentile for height.
10
This plateauing effect
1
Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel
(UZ Brussel), Department of Cardiology, Centrum voor Hart- en
Vaatziekten (CHVZ), Belgium
2
In vivo molecular and cellular imaging (ICMI) centre, Vrije Universiteit
Brussel (VUB), Belgium
Corresponding author:
Bernard Cosyns, Universitair Ziekenhuis Brussel, 101 Laarbeeklaan,
Brussels, Bbt 1090, Belgium.
Email: bcosyns@gmail.com
European Journal of Preventive
Cardiology
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Cardiology 2020
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DOI: 10.1177/2047487319901042
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has been confirmed by other studies.
4,5,11
Therefore
indexing the absolute aortic root dimension for height
or BSA (ratiometric scaling) may not be an accurate
representation of aortic root dilatation as this is based
upon the assumption of linearity, which will overesti-
mate aortic root dimension in subjects who exceed the
95th percentile for height.
Accurate quantification of cardiac dimensions is
essential to distinguish phenotypic overlap between
physiological cardiac remodelling and pathological
structural heart disease. In current clinical practice scal-
ing of cardiovascular structural and functional param-
eters is principally limited to ratiometric scaling (i.e. the
cardiovascular variable is divided by some measure of
body size), which relies on a linear relationship between
the two variables although this is often not the case in
real life. The allometric scaling approach divides the
cardiovascular variable by a body size variable raised
to a scalar exponent. Therefore, allometric scaling may
be a more appropriate scaling compared with ratio-
metric scaling.
12
The study presented by Abulı
´et al. has three main
findings: 1) the aortic root size in healthy trained ath-
letes is within normal ranges established for the general
population; 2) sports with a high dynamic component
are related to significantly larger aortic root size; and
3) allometric and ratiometric scaling to height provides
almost perfect size-independent models, as shown by
the lowest existing relationship with BSA and height
using these scaling methods.
13
This is one of the largest databases available to date.
Moreover, this is the first one that provides reference
aortic root values based on this classification of sports
in skill, power, mixed and endurance. One can regret
that the measurements were only performed in M-mode
and that blood pressure data are not provided. To note
is that only Caucasians were studied and that ethnicity
may play a role in aorta response to exercise. In
athletes, cardiomyopathies are classified according to
the threshold of 35 years old (more congenital below,
more coronary artery disease above). This classification
is debatable for the aorta. Mixing a broad range of
age from 12 to 35 years in the present population
may represent a bias knowing that age may also influ-
ence aortic size and adaptation/remodelling.
Perspectives
It has been shown that vascular characteristics may
vary during the sport season depending on the training
and recovery periods in endurance athletes.
14
This
questions the physiological adaptation of the aorta
versus possible adverse aortic remodelling. This still
needs to be clarified. Additionally, no outcome studies
are currently available.
Ideally, the measurements of the aorta should be
standardized and performed in three dimensions (echo-
cardiography or CMR). Computed tomography is not
recommended in this young population because of
the radiation issues. The potential effect of medical
Sport disciplines
Heart rate
• Golf • Weightlifting • Soccer • Cycling
• Rowing
• Mid-long distance swimming
• Mid-long distance running
• Mid-long distance skating
• Canoeing
• Triathlon
• Pentathlon
• Cross-country skiing
• Basketball
• Volleyball
• Waterpolo
• Tennis
• Cricket
• Fencing
• Handball
• Rugby
• Ice/field hocke
y
• Wrestling
• Boxing
• Judo
• Sprinting
• Discus / javelin
• Alpine skiing
• Snowboarding
• Sailing
• Table tennis
• Equestrian
• Karate
• Shooting
• Car/motor racing
Heart rate
Blood pressure Blood pressure
Cardiac output Cardiac output
+/++
+/++
++/+++
+++/++++
Heart rate
Blood pressure
Cardiac output ++/+++
++/+++
++/+++
Heart rate
Blood pressure
Cardiac output
+++/++++
+++/++++
++/+++
+/++
+
Skill Powe r Mixed Endurance
Figure 1. Schematic classification of sport disciplines according their characteristics (adapted from Pelliccia et al.
6
). Indicates sport
with increased risk of bodily collision.
2European Journal of Preventive Cardiology 0(00)

treatment has to be explored. Finally, the risk of sur-
gery in these patients with aorta enlargement is not
established. The incidence of genetic abnormalities is
unknown in this population. Since a large increase in
aortic size over time is unusual in athletes, a serial
follow-up could be helpful to suspect an underlying
pathology when it occurs, and eventually prompt gen-
etic testing.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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