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 is associated with a spectrum of morphologic and functional cardiac adaptations known as ‘the athlete’s heart’.

A vast amount of literature has been assembled over the last two decades improving our understanding of the characteristics of physiologic cardiac remodelling in athletes. However, there are still areas of uncertainty regarding the differential diagnosis of the most marked expression of the athlete’s heart, with certain inherited cardiac diseases, such as hypertrophic (HCM), dilated (DCM), or arrhythmogenic cardiomyopathy (AC) and left ventricular non-compaction (LVNC) cardiomyopathy.
Indeed, in more recent times, advances in technology, including three-dimensional (3D) echocardiography, speckle tracking echocardiography (STE), cardiac magnetic resonance (CMR), and multi-detector computed tomography (CT) have largely improved the diagnostic capabilities of the modern imaging modalities and made possible the correct identification of a broader spectrum of pathologic cardiovascular conditions that might occur in the athlete’s population.

Long term power training characterises anaerobic sports with mainly static-isometric muscular involvement. These activities can cause structural and electrical changes in the heart that are physiological responses to the gradual increase in systemic arterial resistance, with a predominant pressure overload, responsible of left ventricular (LV) remodelling with increased left ventricular (LV) wall thickness and mass, and unchanged LV chamber size (concentric hypertrophy). On the other hand, endurance training characterises aerobic sports with dynamic-isotonic muscular involvement. These activities cause a gradual decrease in systemic arterial resistance and an increase in venous return, with a predominant volume overload, responsible of structural remodelling as higher LV end-diastolic volume (EDV) and LV mass (eccentric hypertrophy), reduced LV end-systolic volume (ESV) and augmented stroke volume, associated with electrical adaptation as sinus bradycardia.

LV wall thickness by echocardiography can contribute to the distinction between athlete's LV hypertrophy and 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, whereas athletes have a normal diastolic function. When echocardiography cannot provide a clear differential diagnosis, CMR imaging should be performed. With CMR, accurate morphological and functional assessment can be made. 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. The work-up of athletes with suspected coronary artery disease should start with an exercise ECG. In athletes with inconclusive exercise ECG results, exercise stress echocardiography should be considered. Nuclear cardiology techniques, coronary CT and/or CMR may be performed in selected cases. Owing to radiation exposure and the young age of most athletes, the use of CCT and nuclear cardiology techniques should be restricted to athletes with unclear stress echocardiography or CMR and/or with suspected anomalous coronary origin.

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.