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

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 thorn 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/m(2)) than in LGE(-) triathletes (84 +/- 11 g/m(2); p < 0.05). ECV in LGE(-) myocardium was higher in LGE thorn 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. (C) 2018 by the American College of Cardiology Foundation.