Published online before print March 24, 2003, doi: 10.1161/01.HYP.0000064349.20542.AC
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(Hypertension. 2003;41:e6.)
© 2003 American Heart Association, Inc.
Letters to the Editor |
Reliability of Different Echocardiographic Methods in Determining Left Ventricular Mass in Healthy Men and Athletes
Institute of Sports and Preventive Medicine, University of Saarland, Saarbruecken/Homburg, Germany
To the Editor:
We read the interesting paper of Myerson et al entitled "Left Ventricular Mass: Reliability of M-Mode and 2-Dimensional Echocardiographic Formulas".1 The authors determined left ventricular (LV) mass in physically fit and healthy male British Army recruits before and after a 10-week physical training program (obviously an "intensive strength and endurance training"2) by means of echocardiography and the in vivo gold-standard of cardiovascular magnetic resonance (CMR). Compared with CMR, the LV mass was significantly underestimated by use of the M-mode American Society of Echocardiography (ASE)-cube formula of Devereux3 (-14.3 g; -7.8%) and the 2-dimensional (2D) method of Reichek4 (-2.6 g; -1.4%). Furthermore, after the 10-week training program, a significant increase of the LV mass of about 8 g for each method, with standard deviations of 28 g (M-mode), 23 g (2D) and 14 g (CMR), is reported.
It is an important finding that, even in normal hearts, both echocardiographic methods revealed a high scatter of values when compared with CMR, and therefore, CMR should be the preferred modality for examining exercise-induced changes of LV mass, at least in smaller groups.1 However, the reported underestimation of LV mass by echocardiography is in contrast to results of previous studies. Compared with CMR, by use of the ASE-cube formula of Devereux,3 an overestimation of 24 g (11%) and 117 g (with "a variation from -6% to +66% from the mean measurements") was demonstrated by Kuhl et al5 and Devlin et al,6 respectively. In addition, the cited studies of Bottini et al7 and Germain et al8 also demonstrated an overestimation of M-mode echocardiography of 57 g (
25% to 30%) and 14 g (9%), respectively. This overestimation of M-mode or 2D echocardiography has also been demonstrated in many other studies. Although most of these studies were primarily performed in patients, the reported underestimation of LV mass by echocardiography is surprising and should have been discussed more carefully by the authors.
Furthermore, an evaluation of other echocardiographic formulas to determine LV mass would have been of further interest. In an own recent study, four M-mode echocardiographic methods and two 2D-echocardiographic methods were compared with CMR in healthy untrained male subjects and endurance athletes with athlete’s heart.9 In both groups, LV mass was overestimated by all M-mode echocardiographic formulas (including the ASE-cube formula of Devereux3) and—with a minor extent of overestimation—by the 2D method of Reichek,4 whereas only one formula (method of Dickhuth)10 did not differ from CMR determination.
Finally, as commonly accepted by sports cardiologists, it has to be pointed out that a physiological LV hypertrophy—which always has to be related to body dimensions—is typically induced by intensive and high-volume endurance exercise training.11 Therefore, a more precise description of the training program would have been desirable and helpful.
References
1. Myerson SG, Montgomery HE, World MJ, Pennell DJ. Left ventricular mass: reliability of M-mode and 2-dimensional echocardiographic formulas. Hypertension. 2002; 40: 673–678.
2. Montgomery H, Clarkson P, Dollery C, Prasad K, Losi M, Hemingway H, Statters D, Jubb M, Girvain M, Varnava A, World M, Deanfield J, Talmund P, McEwan J, McKenna W, Humphries S. Association of angiotensin-converting enzyme gene I/D polymorphism with change in left ventricular mass in response to physical training. Circulation. 1997; 96: 741–747.
3. Devereux R, Alonso D, Lutas E, Gottlieb G, Campo E, Sachs I, Reichek N. Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol. 1986; 57: 450–458.[CrossRef][Medline] [Order article via Infotrieve]
4. Reichek N, Helak J, Plappert T, Sutton M, Weber K. Anatomic validation of left ventricular mass estimates from clinical two-dimensional echocardiography: initial results. Circulation. 1983; 67: 348–352.
5. Kuhl H, Bucker A, Franke A, Maul S, Nolte-Ernsting C, Reineke T, Hoffmann R, Gunther R, Hanrath P. Transesophageal 3-dimensional echocardiography: in vivo determination of left ventricular mass in comparison with magnetic resonance imaging. J Am Soc Echocardiogr. 2000; 13: 205–215.[Medline] [Order article via Infotrieve]
6. Devlin A, Moore N, Oestman-Smith I. A comparison of MRI and echocardiography in hypertrophic cardiomyopathy. Br J Radiol. 1999; 72: 258–264.[Abstract]
7. Bottini P, Carr A, Prisant L, Flickinger F, Allison J, Gottdiener J. Magnetic resonance imaging compared to echocardiography to assess left ventricular mass in the hypertensive patient. Am J Hypertens. 1995; 8: 221–228.[CrossRef][Medline] [Order article via Infotrieve]
8. Germain P, Roul G, Kastler B, Moussard J, Bareiss P, Sacrez A. Inter-study variability in left ventricular mass measurement. Comparison between M-Mode echocardiography and MRI. Eur Heart J. 1992; 13: 1011–1019.
9. Scharhag J, Urhausen A, Schneider G, Rochette V, Kramann B, Kindermann W. [Left ventricular mass in endurance-athletes with athlete‘s heart and untrained subjects: comparison between different echocardiographic methods and MRI]. Z Kardiol. In press.
10. Dickhuth H, Roeker K, Niess A, Hipp A, Heitkamp H. The echocardiographic determination of volume and muscle mass of the heart. Int J Sports Med. 1996; 17: 132–139.
11. Urhausen A, Kindermann W. Sports-specific adaptions and differentiation of the athlete’s heart. Sports Med. 1999; 28: 237–244.[CrossRef][Medline] [Order article via Infotrieve]
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