and elevations in cardiac biomarkers2
have been described following prolonged exertion in endurance athletes. Yet, despite our subject's extraordinary effort—running and cycling over 3000 km in 27 days while ascending greater than 3900 m—there were no decrements in systolic function or detectable levels of troponin I or T. Conversely, the observation of DE on cardiac MRI at the inferior insertion of the RV and in the IVS is a novel finding, which may suggest subtle inflammation not reflected in echocardiographic indices or cardiac biomarkers.
DE has not been studied extensively in the athlete's heart. Breuckmann et al
demonstrated DE in a low percentage (12%) of older male marathoners, although the distribution was consistent with coronary disease in roughly half and the overall prevalence of DE was not clearly greater than age-matched controls.4
Scharhag et al
assessed for DE in a cohort of 20 highly trained athletes following 1-hour and 3-hour runs at 100% and 75% of the ventilatory threshold, respectively. Despite detectable increases of troponin T in seven subjects, there were no instances of DE on any of the 40 scans.5
Likewise, Mousavi et al
studied 14 moderately trained runners participating in the Manitoba Marathon. All runners had detectable increases in troponin T post-marathon; however, DE was not observed on any of the subjects’ pre-marathon or post-marathon scans.6
DE localising to the insertions of the RV and the IVS has been described in patients with pulmonary hypertension.7 8
While there was no evidence of pulmonary hypertension, RV dilation or RV dysfunction on any of our subject's cardiac MRIs or echocardiograms (all performed at rest), increases in pulmonary vascular resistance secondary to the acute rise in altitude coupled with requisite increases in cardiac output may have led to increased RV strain while running and cycling leading to the pattern of DE observed on cardiac MRI.
In conclusion, despite our subject's extraordinary effort, there was no evidence of cardiac fatigue or elevated cardiac biomarkers. However, the observation of DE at the inferior insertion of the RV and in the IVS may represent subtle inflammation secondary to a combined exercise and altitude effect—a finding which warrants further investigation.
- In the setting of extraordinary exertion, cardiac fatigue or elevated cardiac biomarkers were not observed.
- The DE on post-exertion cardiac MRI is a novel finding suggesting subtle inflammation not reflected in echocardiographic indices or cardiac biomarkers.
- This distribution of DE has been observed in patients with pulmonary hypertension suggesting altitude-associated right ventricular strain due to increases in pulmonary vascular resistance and cardiac output.