The Athlete’s Heart

Table of Contents

Part 1: Dilated Cardiomyopathy

Part 2: Hypertrophic Cardiomyopathy

Part 3: Restrictive Cardiomyopathy

Part 4: Arrhythmogenic Cardiomyopathy

Part 5: LV Non-compaction

Part 6: The Athlete's Heart

Introduction

Athletic training leads to a range of heart shape and function changes known as ‘the athlete’s heart’.

Over the past 20 years, many studies have improved our understanding of normal heart remodelling in athletes. However, it can still be difficult to tell the difference between the most marked forms of the athlete’s heart and some inherited heart diseases, such as hypertrophic (HCM), dilated (DCM), or arrhythmogenic cardiomyopathy (AC) and left ventricular non-compaction (LVNC) cardiomyopathy.
Recent advances in imaging, including three-dimensional (3D) echocardiography, speckle tracking echocardiography (STE), cardiac magnetic resonance (CMR), and multi-detector computed tomography (CT) have largely improved diagnostic accuracy. These tools now allow better detection of a wider range of heart diseases that may affect athletes.

Long-term power training is typical of anaerobic sports and mainly involves static-isometric muscle work. These activities can cause structural and electrical heart changes due to a gradual rise in blood pressure load. These changes mainly affect the left ventricle, leading to thicker walls and increased mass, while cavity size stays normal (concentric hypertrophy). In contrast, endurance training is typical of aerobic sports and involves dynamic muscle work. It leads to lower blood vessel resistance and higher blood return to the heart. This results in a volume load, with larger left‑ventricular filling volume and mass (eccentric hypertrophy), lower end‑systolic volume, higher stroke volume, and electrical changes such as slow heart rate (sinus bradycardia). 

LV wall thickness measured by echocardiography can help distinguish athlete's LV hypertrophy from HCM. LV end-diastolic diameter becomes larger (>55 mm) than the normal limits only in end-stage HCM patients when the LV ejection fraction is <50%. Patients with HCM also show early impairment of LV diastolic function, while athletes have a normal diastolic function. When echocardiography is not conclusive, CMR should be used, as it allows precise assessment of heart structure and function. Tissue characterisation by late gadolinium enhancement may show a distinctive, non-ischaemic pattern in HCM and a variety of other myocardial conditions such as idiopathic DCM, AC, LVNC or myocarditis. In athletes with suspected coronary artery disease, testing should begin with an exercise ECG. If results are unclear, stress echocardiography should be considered. Nuclear imaging, coronary CT, or CMR may be used in selected cases. Because of radiation exposure and the young age of most athletes, CT and nuclear tests should be limited to cases where stress echocardiography or CMR is inconclusive, or when an abnormal coronary origin is suspected.

Presentations

• Echocardiography
• Cardiovascular Magnetic Resonance
• Cardiac CT
• Multimodality Imaging

Resources

Webinars and tutorials

Specific access rules may apply

Athlete's Heart - Multimodality Imaging|
Wednesday 23 September 2015, EACVI

Cardiovascular evaluation in athletes
Friday 05 July 2019, EHRA

Presentations from recent EACVI/ESC congresses

Specific access rules may apply

References and guidelines

• The EACVI Textbook of Echocardiography, 2nd Edition, OUP
  Chapter 55 Systemic disease and other conditions: athlete’s heart
  Antonello D’Andrea, André La Gerche and Christine Selton-Suty
• The ESC Textbook of Cardiovascular Medicine, 3th edition, OUP
  Section 55 Sports and Heart Disease
  Chapter 55.3 Imaging testing for differential diagnosis of the athlete’s heart from structural cardiac diseases . AntonioPellicca
• The ESC Textbook of Sports Cardiology
  Antonio Pelliccia, Hein Heidbuchel, Domenico Corrado, Mats Borjesson , Sanjay Sharma
• Antonio Pelliccia, Stefano Caselli, Sanjay Sharma, Cristina Basso, Jeroen J Bax, Domenico Corrado, Antonello D’Andrea, Flavio D’Ascenzi, Fernando M Di Paolo, Thor Edvardsen, Sabiha Gati, Maurizio Galderisi, Hein Heidbuchel, Alain Nchimi, Koen Nieman, Michael Papadakis, Cataldo Pisicchio, Christian Schmied, Bogdan A Popescu, Gilbert Habib, Diederick Grobbee, Patrizio Lancellotti, Internal reviewers for EAPC and EACVI, European Association of Preventive Cardiology (EAPC) and European Association of Cardiovascular Imaging (EACVI) joint position statement: recommendations for the indication and interpretation of cardiovascular imaging in the evaluation of the athlete’s heart, European Heart Journal, Volume 39, Issue 21, 01 June 2018, Pages 1949–1969, https://doi.org/10.1093/eurheartj/ehx532
• Antonio Pelliccia, Erik Ekker Solberg, Michael Papadakis, Paolo Emilio Adami, Alessandro Biffi, Stefano Caselli, Andrè La Gerche, Josef Niebauer, Axel Pressler, Christian M Schmied, Luis Serratosa, Martin Halle, Frank Van Buuren, Mats Borjesson, Francois Carrè, Nicole M Panhuyzen-Goedkoop, Hein Heidbuchel, Iacopo Olivotto, Domenico Corrado, Gianfranco Sinagra, Sanjay Sharma, Recommendations for participation in competitive and leisure time sport in athletes with cardiomyopathies, myocarditis, and pericarditis: position statement of the Sport Cardiology Section of the European Association of Preventive Cardiology (EAPC), European Heart Journal, Volume 40, Issue 1, 01 January 2019, Pages 19–33, https://doi.org/10.1093/eurheartj/ehy730
• Josef Niebauer, Mats Börjesson, Francois Carre, Stefano Caselli, Paolo Palatini, Filippo Quattrini, Luis Serratosa, Paolo Emilio Adami, Alessandro Biffi, Axel Pressler, Christian Schmied, Frank van Buuren, Nicole Panhuyzen-Goedkoop, Erik Solberg, Martin Halle, André La Gerche, Michael Papadakis, Sanjay Sharma, Antonio Pelliccia, Recommendations for participation in competitive sports of athletes with arterial hypertension: a position statement from the sports cardiology section of the European Association of Preventive Cardiology (EAPC), European Heart Journal, Volume 39, Issue 40, 21 October 2018, Pages 3664–3671, https://doi.org/10.1093/eurheartj/ehy511
• Mats Borjesson, Mikael Dellborg, Josef Niebauer, Andre LaGerche, Christian Schmied, Erik E Solberg, Martin Halle, Emilio Adami, Alessandro Biffi, Francois Carré, Stefano Caselli, Michael Papadakis, Axel Pressler, Hanne Rasmusen, Luis Serratosa, Sanjay Sharma, Frank van Buuren, Antonio Pelliccia, Recommendations for participation in leisure time or competitive sports in athletes-patients with coronary artery disease: a position statement from the Sports Cardiology Section of the European Association of Preventive Cardiology (EAPC), European Heart Journal, Volume 40, Issue 1, 01 January 2019, Pages 13–18, https://doi.org/10.1093/eurheartj/ehy408
• Lluís Mont, Antonio Pelliccia, Sanjay Sharma, Alessandro Biffi, Mats Borjesson, Josep Brugada Terradellas, François Carré, Eduard Guasch, Hein Heidbuchel, André La Gerche, Rachel Lampert, William McKenna, Michail Papadakis, Silvia G Priori, Mauricio Scanavacca, Paul Thompson, Christian Sticherling, Sami Viskin, Mathew Wilson, Domenico Corrado, ESC Scientific Document Group, Pre-participation cardiovascular evaluation for athletic participants to prevent sudden death: Position paper from the EHRA and the EACPR, branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE, EP Europace, Volume 19, Issue 1, January 2017, Pages 139–163, https://doi.org/10.1093/europace/euw243
• Drezner JA, Ashley E, Baggish AL, et al Abnormal electrocardiographic findings in athletes: recognising changes suggestive of cardiomyopathy British Journal of Sports Medicine 2013;47:137-152.