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Sport: friend or foe? Lessons from imaging

Session 104

In the session entitled: “Sport: friend or foe” the speakers were asked to consider whether exercise training could serve as a support to physical therapy, and to describe the main aspects of the athlete’s heart.

In the first presentation, Prof. D’Andrea from Naples (Italy) focused on the possibility of monitoring the beneficial effects of cardiac rehabilitation theraphy by non-invasive imaging. Exercise prescription commonly refers to a specific plan of fitness-related activities that are designed for a specified purpose, which is developed by a fitness or rehabilitation specialist for the individual patient.

An exercise prescription should generally include the following recommendations: (1) Type of exercise or activity (endurance/training), (2) Specific workloads, (3) Duration and frequency of the activity or exercise session, (4) Intensity guidelines including target heart rate range and estimated rate of perceived exertion.


Using both clinical evaluation and imaging techniques, the cardiologist should perform the initial assessment, management and stabilization of the patient. Exercise stress test has then a pivotal role in the evaluation of functional capacity, and a regular clinical follow-up is necessary for the reassessment of symptoms, exercise progress and cardiac remodeling

During regular clinical follow-up for exercise progress and symptoms reassessment, the cardiologist should evaluate the progress of exercise tolerance, evaluate cardiac remodeling and ischemic burden, and if necessary, modify the prescription according to the improvement in fitness.

In the second presentation, Prof. Galderisi from Naples (Italy) focused on the chronic adaptations typical of the athlete’s heart. A multi-modality imaging approach to the athlete’s heart aims to differentiate physiological changes due to intensive training from serious cardiac diseases with similar morphological features. Imaging assessment of the athlete should begin with a thorough echocardiographic examination. The measure of left ventricular (LV) wall thickness by echocardiography can contribute to the distinction between athlete’s LV hypertrophy and hypertrophic cardiomyopathy (HCM). In patients with HCM, the LV end-diastolic diameter exceeds normal limits only in the end-stage of the disease, when the LV ejection fraction is ≤50%. Patients with HCM also show early impairment of LV diastolic function, whereas athletes have normal diastolic function. When echocardiography cannot provide a clear differential diagnosis, cardiac magnetic resonance imaging (CMRI) should be performed. CMRI allows an accurate morphological and functional assessment of the heart. Tissue characterization by late gadolinium enhancement may show a distinctive, non-ischaemic pattern in HCM, which can help in differentiating this pathology from other myocardial diseases, such as idiopathic dilated cardiomyopathy or myocarditis.

In the third presentation, Prof. Nagueh from Houston (US) underlined the utility of a multi-modality approach for the evaluation of HCM. In HCM patients, imaging provides solutions for most clinical needs, from diagnosis to prognosis and risk stratification, from anatomical and functional assessment to ischemia detection, from metabolic evaluation to monitoring of treatment modalities, from staging to follow-up, and from family screening and preclinical diagnosis to differential diagnosis. Accordingly, a multimodality imaging approach (including echocardiography, CMR, cardiac computed tomography, and cardiac nuclear imaging) is encouraged in the assessment of these patients. The choice of which technique to use should be based on a broad perspective and expert knowledge of what each technique has to offer, including its specific advantages and disadvantages.

In the final presentation, Dr G. Claessen from Leuven (Belgium) underlined the effects of extreme sports on right ventricular (RV) function. While strength training seems to impact minimally on the right ventricle, endurance exercise is associated with the most extensive cardiac remodelling. Previous reports have described a disproportionate load on RV, during exercise, and this might be the basis for chronic pro-arrhythmic RV remodelling. Indeed, while the reversibility of the changes induced by sport after detraining is considered a typical feature of athlete’s heart, several studies have shown that recovery might be incomplete, in particular for RV changes and this is particularly true in more highly trained athletes.

In conclusion, the type, intensity and the duration of sports training should be strongly considered together with other factors (age, male sex, black ethnicity, body surface area) as the main determinants of cardiovascular adaptations to physical exercise.  

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.