Management of Left Ventricular Dysfunction in Ultra-Marathon Athletes

Initial Assessment and Establishing Baseline

The American College of Cardiology recommends initial echocardiography within 2-3 months to establish chronicity and stability in ultra-marathon athletes with left ventricular dysfunction 1, 2
Two-dimensional echocardiography with Doppler should be used to assess LVEF, LV size, wall thickness, regional wall motion abnormalities, and valve function in ultra-marathon athletes with left ventricular dysfunction 1, 2
A 12-lead ECG should be performed to evaluate for arrhythmias, conduction abnormalities, or LV hypertrophy in ultra-marathon athletes with left ventricular dysfunction 1, 2
Complete blood count, comprehensive metabolic panel including electrolytes, renal function, liver function tests, and thyroid-stimulating hormone should be performed in ultra-marathon athletes with left ventricular dysfunction 1

For ultra-marathon athletes with mild left ventricular dysfunction and normal or near-normal LV size, clinical evaluation should be performed annually with detailed history and physical examination 3, 4, 6
For ultra-marathon athletes with mild left ventricular dysfunction and normal or near-normal LV size, echocardiography should be performed every 2-3 years unless clinical evidence suggests worsening 3, 4, 6
For ultra-marathon athletes with significant left ventricular dysfunction or dilatation, clinical evaluation should be performed every 6 months including detailed history, physical examination, and assessment of functional capacity 3, 4, 5, 6, 7
For ultra-marathon athletes with significant left ventricular dysfunction or dilatation, echocardiography should be performed every 6-12 months depending on severity and stability of measurements 3, 4, 5, 6, 7

Functional capacity and ability to perform activities of daily living should be monitored in ultra-marathon athletes with left ventricular dysfunction 1, 2
Volume status including jugular venous distension, peripheral edema, pulmonary rales, and S3 gallop should be monitored in ultra-marathon athletes with left ventricular dysfunction 2
Orthostatic blood pressure changes should be monitored in ultra-marathon athletes with left ventricular dysfunction 1, 2
New or changing symptoms including dyspnea, exercise intolerance, or chest pain should be monitored in ultra-marathon athletes with left ventricular dysfunction 3, 4, 5, 7

Repeat echocardiography should be performed sooner than scheduled if new or worsening symptoms develop in ultra-marathon athletes with left ventricular dysfunction 3, 4, 5, 7
Repeat echocardiography should be performed sooner than scheduled if clinical findings suggest worsening dysfunction in ultra-marathon athletes with left ventricular dysfunction 3, 4, 5, 7
If apparent significant fall in EF or increase in LV dimensions, repeat imaging should be performed at 3-6 month intervals in ultra-marathon athletes with left ventricular dysfunction 8

The patient should cease ultra-marathon training until stability is established and LV function improves, as recommended by the ACC/AHA guidelines 6, 7
Before any return to competitive athletics, exercise testing to at least the level of proposed activity is mandatory to evaluate tolerance in ultra-marathon athletes with left ventricular dysfunction 6, 7
Consider coronary angiography or CT coronary angiography to exclude underlying CAD in ultra-marathon athletes with left ventricular dysfunction, particularly if there are any symptoms suggestive of ischemia or if risk factors are present 1, 2