Structural features of the athlete heart as defined by echocardiography

The morphologic concepts of the "athlete heart" have been enhanced and clarified over the last 10 years by virtue of M-mode echocardiographic studies performed on more than 1,000 competitive athletes. Long-term athletic training produces relatively mild but predictable alterations in cardiac structure that result in an increase in calculated left ventricular mass. This increase in mass observed in highly trained athletes is due to a mild increase in either transverse end-diastolic dimension of the left ventricle or left ventricular wall thickness, or both. Cardiac dimensions in athletes compared with matched control subjects show increases of about 10% for left ventricular end-diastolic dimension, about 15 to 20% for wall thickness and about 45% for calculated left ventricular mass. Furthermore, there is evidence that the modest degree of "physiologic" left ventricular hypertrophy (both the cavity dilation and wall thickening) observed in athletes is dynamic in nature, that is, it may develop rapidly within weeks or months after the initiation of vigorous conditioning and may be reversed in a similar time period after the cessation of training. Several echocardiographic studies also suggest that the precise alterations in cardiac structure associated with training may differ depending on the type of athletic activity undertaken (that is, whether training is primarily dynamic [isotonic] or static [isometric]). Although the ventricular septal to free wall thickness ratio (on M-mode echocardiogram) is almost always within normal limits (less than 1.3), occasionally an athlete will show mild asymmetric thickening of the anterior basal septum (usually 13 to 15 mm). This circumstance may mimic certain pathologic conditions characterized by primary left ventricular hypertrophy such as nonobstructive hypertrophic cardiomyopathy. The long-term significance of increased left ventricular mass in trained athletes has not been conclusively defined. However, there is no evidence at this time suggesting that this form of hypertrophy is itself deleterious to the athlete or predisposes to (or prevents) the natural occurrence of cardiovascular disease later in life.

This article has been cited by other articles:

				A D'Andrea, G De Corato, R Scarafile, S Romano, L Reigler, C Mita, F Allocca, G Limongelli, G Gigantino, B Liccardo, et al. Left atrial myocardial function in either physiological or pathological left ventricular hypertrophy: a two-dimensional speckle strain study Br. J. Sports Med., August 1, 2008; 42(8): 696 - 702. [Abstract] [Full Text] [PDF]

				D. J. Duncker and R. J. Bache Regulation of Coronary Blood Flow During Exercise Physiol Rev, July 1, 2008; 88(3): 1009 - 1086. [Abstract] [Full Text] [PDF]

				S. Basavarajaiah, M. Wilson, G. Whyte, A. Shah, W. McKenna, and S. Sharma Prevalence of hypertrophic cardiomyopathy in highly trained athletes: relevance to pre-participation screening. J. Am. Coll. Cardiol., March 11, 2008; 51(10): 1033 - 1039. [Abstract] [Full Text] [PDF]

				P. De Mozzi, U. G. Longo, G. Galanti, and N. Maffulli Bicuspid aortic valve: a literature review and its impact on sport activity Br. Med. Bull., March 1, 2008; 85(1): 63 - 85. [Abstract] [Full Text] [PDF]

				P. Luthi, M. Zuber, M. Ritter, E. N. Oechslin, R. Jenni, B. Seifert, S. Baldesberger, and C. H. Attenhofer Jost Echocardiographic findings in former professional cyclists after long-term deconditioning of more than 30 years Eur J Echocardiogr, March 1, 2008; 9(2): 261 - 267. [Abstract] [Full Text] [PDF]

				F. J. Calderon Montero, P. J. Benito Peinado, V. Di Salvo, F. Pigozzi, and N. Maffulli Cardiac adaptation to training and decreased training loads in endurance athletes: a systematic review Br. Med. Bull., December 1, 2007; 84(1): 25 - 35. [Abstract] [Full Text] [PDF]

				R. Q Osborn, W. C Taylor, K. Oken, M. Luzano, M. Heckman, and G. Fletcher Echocardiographic characterisation of left ventricular geometry of professional male tennis players Br. J. Sports Med., November 1, 2007; 41(11): 789 - 792. [Abstract] [Full Text] [PDF]

				M M. Lindsay and F. G Dunn Biochemical evidence of myocardial fibrosis in veteran endurance athletes Br. J. Sports Med., July 1, 2007; 41(7): 447 - 452. [Abstract] [Full Text] [PDF]

				A. Dzudie, A. Menanga, B. Hamadou, A. P. Kengne, G. Atchou, and S. Kingue Ultrasonographic study of left ventricular function at rest in a group of highly trained black African handball players Eur J Echocardiogr, March 1, 2007; 8(2): 122 - 127. [Abstract] [Full Text] [PDF]

				A. D'Andrea, P. Caso, G. Salerno, R. Scarafile, G. De Corato, C. Mita, G. Di Salvo, S. Severino, S. Cuomo, B. Liccardo, et al. Left ventricular early myocardial dysfunction after chronic misuse of anabolic androgenic steroids: a Doppler myocardial and strain imaging analysis * COMMENTARY Br. J. Sports Med., March 1, 2007; 41(3): 149 - 155. [Abstract] [Full Text] [PDF]

				B. J. Maron and A. Pelliccia The Heart of Trained Athletes: Cardiac Remodeling and the Risks of Sports, Including Sudden Death Circulation, October 10, 2006; 114(15): 1633 - 1644. [Full Text] [PDF]

				M. A. Perhonen, P. Haapalahti, S. Kivisto, A.-M. Hekkala, H. Vaananen, H. Swan, and L. Toivonen Effect of physical training on ventricular repolarization in type 1 long QT syndrome: a pilot study in asymptomatic carriers of the G589D KCNQ1 mutation Europace, October 1, 2006; 8(10): 894 - 898. [Abstract] [Full Text] [PDF]

				L. E. Young, K. Rogers, and J. L. N. Wood Left ventricular size and systolic function in Thoroughbred racehorses and their relationships to race performance J Appl Physiol, October 1, 2005; 99(4): 1278 - 1285. [Abstract] [Full Text] [PDF]

				J Makan, S Sharma, S Firoozi, G Whyte, P G Jackson, and W J McKenna Physiological upper limits of ventricular cavity size in highly trained adolescent athletes Heart, April 1, 2005; 91(4): 495 - 499. [Abstract] [Full Text] [PDF]

				L. H Naylor, L. F Arnolda, J. A Deague, D. Playford, A. Maurogiovanni, G. O'Driscoll, and D. J Green Reduced ventricular flow propagation velocity in elite athletes is augmented with the resumption of exercise training J. Physiol., March 15, 2005; 563(3): 957 - 963. [Abstract] [Full Text] [PDF]

				J. M. Goodman, P. P. Liu, and H. J. Green Left ventricular adaptations following short-term endurance training J Appl Physiol, February 1, 2005; 98(2): 454 - 460. [Abstract] [Full Text] [PDF]

				K. Soejima and W. G. Stevenson Athens, athletes, and arrhythmias: The cardiologist's dilemma J. Am. Coll. Cardiol., September 1, 2004; 44(5): 1059 - 1061. [Full Text] [PDF]

				E. Abergel, G. Chatellier, A. A. Hagege, A. Oblak, A. Linhart, A. Ducardonnet, and J. Menard Serial left ventricular adaptations in world-class professional cyclists: Implications for disease screening and follow-up J. Am. Coll. Cardiol., July 7, 2004; 44(1): 144 - 149. [Abstract] [Full Text] [PDF]

				J. Hoogsteen, G. Schep, N. M. van Hemel, and E. E. van der Wall Paroxysmal atrial fibrillation in male endurance athletes. A 9-year follow up Europace, January 1, 2004; 6(3): 222 - 228. [Abstract] [Full Text] [PDF]

				S Firoozi, S Sharma, and W J McKenna Risk of competitive sport in young athletes with heart disease Heart, July 1, 2003; 89(7): 710 - 714. [Abstract] [Full Text] [PDF]

				S. G. Myerson and D. J. Pennell Response Hypertension, May 1, 2003; e7(5): . [Full Text] [PDF]

				W. B. Abernethy III, J. K. Choo, and A. M. Hutter Jr Echocardiographic characteristics of professional football players J. Am. Coll. Cardiol., January 15, 2003; 41(2): 280 - 284. [Abstract] [Full Text] [PDF]

				J.u. Scharhag, G.u. Schneider, A. Urhausen, V. Rochette, B. Kramann, and W. Kindermann Athlete's heart: Right and left ventricular mass and function in male endurance athletes and untrained individuals determined by magnetic resonance imaging J. Am. Coll. Cardiol., November 20, 2002; 40(10): 1856 - 1863. [Abstract] [Full Text] [PDF]

				S. Sharma, B. J. Maron, G. Whyte, S. Firoozi, P. M. Elliott, and W. J. McKenna Physiologic limits of left ventricular hypertrophy in elite junior athletes: Relevance to differential diagnosis of athlete's heart and hypertrophic cardiomyopathy J. Am. Coll. Cardiol., October 16, 2002; 40(8): 1431 - 1436. [Abstract] [Full Text] [PDF]

				D. L. King, L. El-Khoury Coffin, and M. S. Maurer Myocardial contraction fraction: a volumetric index of myocardial shortening by freehand three-dimensional echocardiography J. Am. Coll. Cardiol., July 17, 2002; 40(2): 325 - 329. [Abstract] [Full Text] [PDF]

				A. Hinderliter, A. Sherwood, E. C. D. Gullette, M. Babyak, R. Waugh, A. Georgiades, and J. A. Blumenthal Reduction of Left Ventricular Hypertrophy After Exercise and Weight Loss in Overweight Patients With Mild Hypertension Arch Intern Med, June 24, 2002; 162(12): 1333 - 1339. [Abstract] [Full Text] [PDF]

				D J R Hildick-Smith and L M Shapiro Echocardiographic differentiation of pathological and physiological left ventricular hypertrophy Heart, June 1, 2001; 85(6): 615 - 619. [Full Text]

				J D Somauroo, J R Pyatt, M Jackson, R A Perry, and D R Ramsdale An echocardiographic assessment of cardiac morphology and common ECG findings in teenage professional soccer players: reference ranges for use in screening Heart, June 1, 2001; 85(6): 649 - 654. [Abstract] [Full Text]

				S. G. Myerson, H. E. Montgomery, M. Whittingham, M. Jubb, M. J. World, S. E. Humphries, and D. J. Pennell Left Ventricular Hypertrophy With Exercise and ACE Gene Insertion/Deletion Polymorphism : A Randomized Controlled Trial With Losartan Circulation, January 16, 2001; 103(2): 226 - 230. [Abstract] [Full Text] [PDF]

				R. J. Spina, S. Rashid, V. G. Davila-Roman, and A. A. Ehsani Adaptations in beta -adrenergic cardiovascular responses to training in older women J Appl Physiol, December 1, 2000; 89(6): 2300 - 2305. [Abstract] [Full Text] [PDF]

				D J R Hildick-Smith, P J Johnson, C R Wisbey, E M Winter, and L M Shapiro Coronary flow reserve is supranormal in endurance athletes: an adenosine transthoracic echocardiographic study Heart, October 1, 2000; 84(4): 383 - 389. [Abstract] [Full Text]

				S. Sharma, P. M. Elliott, G. Whyte, N. Mahon, M. S. Virdee, B. Mist, and W. J. McKenna Utility of metabolic exercise testing in distinguishing hypertrophic cardiomyopathy from physiologic left ventricular hypertrophy in athletes J. Am. Coll. Cardiol., September 1, 2000; 36(3): 864 - 870. [Abstract] [Full Text] [PDF]

				Y. Eto, K. Yonekura, M. Sonoda, N. Arai, M. Sata, S. Sugiura, K. Takenaka, A. Gualberto, M. L. Hixon, M. W. Wagner, et al. Calcineurin Is Activated in Rat Hearts With Physiological Left Ventricular Hypertrophy Induced by Voluntary Exercise Training Circulation, May 9, 2000; 101(18): 2134 - 2137. [Abstract] [Full Text] [PDF]

				O. E. Suman, D. Hasten, M. J. Turner, M. R. Rinder, R. J. Spina, and A. A. Ehsani Enhanced inotropic response to dobutamine in strength-trained subjects with left ventricular hypertrophy J Appl Physiol, February 1, 2000; 88(2): 534 - 539. [Abstract] [Full Text] [PDF]

				B. M. Pluim, A. H. Zwinderman, A. van der Laarse, and E. E. van der Wall The Athlete’s Heart : A Meta-Analysis of Cardiac Structure and Function Circulation, January 25, 2000; 101(3): 336 - 344. [Abstract] [Full Text] [PDF]

				T. O. Takala, P. Nuutila, C. Katoh, M. Luotolahti, J. Bergman, M. Maki, V. Oikonen, U. Ruotsalainen, T. Gronroos, M. Haaparanta, et al. Myocardial blood flow, oxygen consumption, and fatty acid uptake in endurance athletes during insulin stimulation Am J Physiol Endocrinol Metab, October 1, 1999; 277(4): E585 - E590. [Abstract] [Full Text] [PDF]

				J. Karjalainen, U. M. Kujala, A. Stolt, M. Mantysaari, M. Viitasalo, K. Kainulainen, and K. Kontula Angiotensinogen gene M235T polymorphism predicts left ventricular hypertrophy in endurance athletes J. Am. Coll. Cardiol., August 1, 1999; 34(2): 494 - 499. [Abstract] [Full Text] [PDF]

				B M Pluim, C A Swenne, A H Zwinderman, A C Maan, A van der Laarse, J Doornbos, and E E Van der Wall Correlation of heart rate variability with cardiac functional and metabolic variables in cyclists with training induced left ventricular hypertrophy Heart, June 1, 1999; 81(6): 612 - 617. [Abstract] [Full Text]

				T. O. Takala, P. Nuutila, J. Knuuti, M. Luotolahti, and H. Yki-Jarvinen Insulin action on heart and skeletal muscle glucose uptake in weight lifters and endurance athletes Am J Physiol Endocrinol Metab, April 1, 1999; 276(4): E706 - E711. [Abstract] [Full Text] [PDF]

				A. Pelliccia, F. Culasso, F. M. Di Paolo, and B. J. Maron Physiologic Left Ventricular Cavity Dilatation in Elite Athletes Ann Intern Med, January 5, 1999; 130(1): 23 - 31. [Abstract] [Full Text] [PDF]

				F. C. Basilico Cardiovascular Disease in Athletes Am. J. Sports Med., January 1, 1999; 27(1): 108 - 121. [Abstract] [Full Text] [PDF]

				R. L. Stepien, K. W. Hinchcliff, P. D. Constable, and J. Olson Effect of endurance training on cardiac morphology in Alaskan sled dogs J Appl Physiol, October 1, 1998; 85(4): 1368 - 1375. [Abstract] [Full Text] [PDF]

				B. M. Pluim, H. J. Lamb, H. W. M. Kayser, F. Leujes, H. P. Beyerbacht, A. H. Zwinderman, A. van der Laarse, H. W. Vliegen, A. de Roos, and E. E. van der Wall Functional and Metabolic Evaluation of the Athlete's Heart By Magnetic Resonance Imaging and Dobutamine Stress Magnetic Resonance Spectroscopy Circulation, February 24, 1998; 97(7): 666 - 672. [Abstract] [Full Text] [PDF]

				N R SONI and J E DEANFIELD Assessment of cardiovascular fitness for competitive sport in high risk groups Arch. Dis. Child., November 1, 1997; 77(5): 386 - 389. [Full Text]

				J. Karjalainen, M. Mantysaari, M. Viitasalo, and U. Kujala Left ventricular mass, geometry, and filling in endurance athletes: association with exercise blood pressure J Appl Physiol, February 1, 1997; 82(2): 531 - 537. [Abstract] [Full Text] [PDF]

				B. J. Maron, P. D. Thompson, J. C. Puffer, C. A. McGrew, W. B. Strong, P. S. Douglas, L. T. Clark, M. J. Mitten, M. H. Crawford, D. L. Atkins, et al. Cardiovascular Preparticipation Screening of Competitive Athletes: A Statement for Health Professionals From the Sudden Death Committee (Clinical Cardiology) and Congenital Cardiac Defects Committee (Cardiovascular Disease in the Young), American Heart Association Circulation, August 15, 1996; 94(4): 850 - 856. [Full Text]

				P. F. Kokkinos, P. Narayan, J. A. Colleran, A. Pittaras, A. Notargiacomo, D. Reda, and V. Papademetriou Effects of Regular Exercise on Blood Pressure and Left Ventricular Hypertrophy in African-American Men with Severe Hypertension N. Engl. J. Med., November 30, 1995; 333(22): 1462 - 1467. [Abstract] [Full Text] [PDF]

				B. J. Maron, A. Pelliccia, and P. Spirito Cardiac Disease in Young Trained Athletes : Insights Into Methods for Distinguishing Athlete's Heart From Structural Heart Disease, With Particular Emphasis on Hypertrophic Cardiomyopathy Circulation, March 1, 1995; 91(5): 1596 - 1601. [Full Text]

				G. G. Neri Serneri, M. Boddi, P. A. Modesti, I. Cecioni, M. Coppo, L. Padeletti, A. Michelucci, A. Colella, and G. Galanti Increased Cardiac Sympathetic Activity and Insulin-Like Growth Factor-I Formation Are Associated With Physiological Hypertrophy in Athletes Circ. Res., November 23, 2001; 89(11): 977 - 982. [Abstract] [Full Text] [PDF]

				A. Pelliccia, B. J. Maron, R. De Luca, F. M. Di Paolo, A. Spataro, and F. Culasso Remodeling of Left Ventricular Hypertrophy in Elite Athletes After Long-Term Deconditioning Circulation, February 26, 2002; 105(8): 944 - 949. [Abstract] [Full Text] [PDF]