The differentiation of the competitive athlete with physiologic cardiac remodeling from the athlete with cardiomyopathy

• Published in: Current problems in cardiology 2024-09, Vol.49 (9), p.102473, Article 102473
• Main Author: Henning, Robert J.
• Format: Article
• Language: English
• Subjects: Athlete echocardiogram; Athlete's heart; Athletes; Cardiomegaly, Exercise-Induced - physiology; Cardiomyopathies - diagnosis; Cardiomyopathies - physiopathology; Cardiomyopathy; Diagnosis, Differential; Echocardiography - methods; Electrocardiography; Humans; Implantable cardioverters-defibrillators; International criteria for athlete ECG; Pharmacologic therapy; Ventricular Remodeling - physiology
• ISSN: 0146-2806; 1535-6280; 1535-6280
• DOI: 10.1016/j.cpcardiol.2024.102473

There are currently 5 million active high school, collegiate, professional, and master athletes in the United States. Regular intense exercise by these athletes can promote structural, electrical and functional remodeling of the heart, which is termed the “athlete's heart.” In addition, regular intense exercise can lead to pathological adaptions that promote or worsen cardiac disease. Many of the athletes in the United States seek medical care. Consequently, physicians must be aware of the normal cardiac anatomy and physiology of the athlete, the differentiation of the normal athlete heart from the athlete with cardiomyopathy, and the contemporary care of the athlete with a cardiomyopathy. In athletes with persistent cardiovascular symptoms, investigations should include a detailed history and physical examination, an ECG, a transthoracic echocardiogram, and in athletes in whom the diagnosis is uncertain, a maximal exercise stress test or a continuous ECG recording, and cardiac magnetic resonance imaging or cardiac computed tomography angiography when definition of the coronary anatomy or characterization of the aorta and the aortic great vessels is indicated. This article discusses the differentiation of the normal athlete with physiologic cardiac remodeling from the athlete with hypertrophic, dilated or arrhythmogenic ventricular cardiomyopathy (ACM). The ECG changes in trained athletes that are considered normal, borderline, or abnormal are listed. In addition, the normal echocardiographic measurements for athletes who consistently participate in endurance, power, combined or heterogeneous sports are enumerated and discussed. Algorithms are listed that are useful in the diagnosis of trained athletes with borderline or abnormal echocardiographic measurements suggestive of cardiomyopathies along with the major and minor criteria for the diagnosis of ACM in athletes. Thereafter, the treatment of athletes with hypertrophic, dilated, and arrhythmogenic right ventricular cardiomyopathies are reviewed. The distinction between physiologic changes and pathologic changes in the hearts of athletes has important therapeutic and prognostic implications. Failure by the physician to correctly diagnose an athlete with hypertrophic cardiomyopathy, dilated cardiomyopathy, or ACM, can lead to the sudden cardiac arrest and death of the athlete during training or sports competition. Conversely, an incorrect diagnosis by a physician of cardiac pathology in a normal athlete c