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Athlete’s Heart

By

Robert S. McKelvie

, MD, PhD, Western University

Medically Reviewed Sep 2022
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Athlete’s heart is a constellation of structural and functional changes that occur in the heart of people who train for prolonged durations (eg,> 1 hour most days) and/or frequently at high intensities. The changes are asymptomatic; signs include bradycardia, a systolic murmur, and extra heart sounds. Electrocardiographic (ECG) abnormalities are common. Diagnosis is clinical or by echocardiography. No treatment is necessary. Athlete’s heart is significant because it must be distinguished from serious cardiac disorders.

Intensive, prolonged endurance and strength training causes many physiologic adaptations. Volume and pressure loads in the left ventricle (LV) increase, which, over time, increase LV muscle mass, wall thickness, and chamber size. Maximal stroke volume and cardiac output increase, contributing to a lower resting heart rate and longer diastolic filling time. Lower heart rate results primarily from increased vagal tone, but decreased sympathetic activation and other nonautonomic factors that decrease intrinsic sinus node activity may play a role. Bradycardia decreases myocardial oxygen demand; at the same time, increases in total hemoglobin and blood volume enhance oxygen transport. Despite these changes, systolic function and diastolic function remain normal. Structural changes in women are typically less than those in men of the same age, body size, and level of training (1, 2 General references Athlete’s heart is a constellation of structural and functional changes that occur in the heart of people who train for prolonged durations (eg,> 1 hour most days) and/or frequently at high... read more ).

The prevalence of coronary artery calcium (CAC) scores greater than or equal to 100 Agatston units appears to be increased in people performing high levels of physical activity (equal to or more than 3000 MET [metabolic equivalent of task]-minutes/week) than those performing lower levels of physical activity. However, this does not translate into a greater risk of all-cause or cardiovascular mortality . The data support that even in the presence of CAC the risk of all-cause mortality and CV mortality is less with high levels of physical activity than with lower levels of physical activity (3 General references Athlete’s heart is a constellation of structural and functional changes that occur in the heart of people who train for prolonged durations (eg,> 1 hour most days) and/or frequently at high... read more ).

General references

  • 1. Brosnan MJ, Rakit D: Differentiating athlete's heart from cardiomyopathies − The left side. Heart Lung Circ 27(9):1052-1062, 2018. doi: 10.1016/j.hlc.2018.04.297

  • 2. Martinez MW, Kim JH, Shah AB, et al: Exercise-induced cardiovascular adaptations and approach to exercise and cardiovascular disease. JACC State-Of-The-Art Review. J Am Coll Cardiol 78 (14): 1454–1470, 2021. doi: 10.1016/j.jacc.2021.08.003

  • 3. DeFina LF, Radford NB, Barlow CE, et al: Association of all-cause and cardiovascular mortality with high levels of physical activity and concurrent coronary artery calcification. JAMA Cardiol. 4(2):174–181, 2019. doi:10.1001/jamacardio.2018.4628

Symptoms and Signs of Athlete’s Heart

There are no symptoms. Signs vary but may include

  • Bradycardia

  • An LV impulse that is laterally displaced, enlarged, and increased in amplitude

  • A systolic ejection (flow) murmur at the left lower sternal border

  • A 3rd heart sound (S3) due to early, rapid diastolic ventricular filling

  • A 4th heart sound (S4), heard best during resting bradycardia because diastolic filling time is increased

  • Hyperdynamic carotid pulses

These signs reflect structural cardiac changes that are adaptive for intense exercise.

Diagnosis of Athlete’s Heart

  • Clinical evaluation

  • Usually ECG

  • Sometimes echocardiography

  • Rarely, cardiac magnetic resonance imaging

  • Rarely, stress testing

Findings are typically detected during routine screening or during evaluation of unrelated symptoms. Most athletes do not require extensive testing, although ECG is often warranted. If symptoms suggest a cardiac disorder (eg, palpitations, chest pain), ECG, echocardiography, and exercise stress testing are done.

ECG

Numerous changes in rhythm and ECG morphology can occur; they correlate poorly with level of training and cardiovascular performance. The most common ECG finding is

  • Sinus bradycardia

Rarely, heart rate is < 40 beats/minute. Sinus arrhythmia often accompanies the slow heart rate. Resting bradycardia may also predispose to

  • Atrial or ventricular ectopy (including couplets and bursts of nonsustained ventricular tachycardia); pauses after ectopic beats do not exceed 4 seconds

  • Wandering supraventricular pacemaker

Other ECG findings that may occur include

  • First-degree atrioventricular (AV) block (in up to one third of athletes)

  • Second-degree AV block (mainly type I); this finding occurs during rest and disappears with exercise

  • High-voltage QRS with inferolateral T-wave changes (reflecting LV hypertrophy)

  • Deep anterolateral T-wave inversion

  • Incomplete right bundle branch block

These ECG and rhythm changes have not been associated with adverse clinical events, suggesting that various arrhythmias are not abnormal in athletes. The arrhythmias are usually abolished or substantially reduced after a relatively brief period of deconditioning.

Echocardiography

Echocardiography can usually distinguish athlete’s heart from cardiomyopathies (see table Features Distinguishing Athlete's Heart From Cardiomyopathy Features Distinguishing Athlete's Heart From Cardiomyopathy Features Distinguishing Athlete's Heart From Cardiomyopathy ), but the distinction is not always clear because there is a continuum from physiologic to pathologic cardiac enlargement. The zone of overlap between athlete’s heart and cardiomyopathy is left ventricular septal thickness:

  • In men, 13 to 15 mm

  • In women, 11 to 13 mm

In this overlap area, the presence of mitral valve systolic anterior motion strongly suggests hypertrophic cardiomyopathy Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy is a congenital or acquired disorder characterized by marked ventricular hypertrophy with diastolic dysfunction (eg, due to valvular aortic stenosis, coarctation... read more Hypertrophic Cardiomyopathy . Also, diastolic indexes may be abnormal in cardiomyopathy but are usually normal in athlete's heart. In general, echocardiographic changes correlate poorly with level of training and cardiovascular performance. Trace mitral regurgitation and tricuspid regurgitation are commonly detected. Of note, reduction of physical training will result in regression of cardiac enlargement in patients with athlete's heart but not in those with cardiomyopathy. Exercise echocardiography may help to differentiate athlete's heart from dilated cardiomyopathy Dilated Cardiomyopathy Dilated cardiomyopathy is myocardial dysfunction causing heart failure in which ventricular dilation and systolic dysfunction predominate. Symptoms include dyspnea, fatigue, and peripheral edema... read more Dilated Cardiomyopathy . In one study, a change during exercise in left ventricular ejection fraction (LVEF) 11% and a peak LVEF 63% during exercise predicted dilated cardiomyopathy with a sensitivity of 85.7% and specificity of 92% (2 Diagnosis references Athlete’s heart is a constellation of structural and functional changes that occur in the heart of people who train for prolonged durations (eg,> 1 hour most days) and/or frequently at high... read more ).

Cardiac magnetic resonance (CMR) imaging

Although confirmation in large studies is pending, data so far suggest that CMR may also help differentiate athlete's heart from cardiomyopathy. In hypertrophic cardiomyopathy (3 Diagnosis references Athlete’s heart is a constellation of structural and functional changes that occur in the heart of people who train for prolonged durations (eg,> 1 hour most days) and/or frequently at high... read more ), CMR may identify focal hypertrophy not identified on the echocardiogram, particularly in the apex, anterior free wall, and posterior septum. Delayed imaging after injection of contrast may show a typical pattern of mid-wall fibrosis in some patients with hypertrophic cardiomyopathy, particularly in left ventricular wall segments that exhibit maximal hypertrophy. However, this finding is absent in up to 60% of patients with hypertrophic cardiomyopathy.

Delayed enhancement on CMR is also evident in nonischemic dilated cardiomyopathy and may help differentiate dilated cardiomyopathy from athlete's heart. However, the finding is absent in 68% of patients with genetically proven dilated cardiomyopathy. T1 and T2 mapping, extracellular volume quantification, late gadolinium enhancement, deformation imaging and diffusion tensor imaging are all promising techniques to differentiate between athlete's heart and hypertrophic cardiomyopathy. Further studies are required to better determine the ability of these techniques to detect hypertrophic cardiomyopathy in athletes (4, 5 Diagnosis references Athlete’s heart is a constellation of structural and functional changes that occur in the heart of people who train for prolonged durations (eg,> 1 hour most days) and/or frequently at high... read more ). Although exercise capacity as measured by stress testing does not differentiate between athlete's heart and dilated cardiomyopathy, reduced cardiac contractile reserve with exercise observed on CMR imaging may be useful in establishing a diagnosis of dilated cardiomyopathy in an athlete.

Stress testing

During exercise stress testing Stress Testing In stress testing, the heart is monitored by electrocardiography (ECG) and often imaging studies during an induced episode of increased cardiac demand so that ischemic areas potentially at risk... read more Stress Testing , heart rate remains lower than normal at submaximal stress and increases appropriately and comparably to heart rate in nonathletes at maximal stress; it rapidly recovers after exercise. Blood pressure response is normal if:

  • Systolic blood pressure increases

  • Diastolic blood pressure falls

  • Mean blood pressure stays relatively constant

Many resting ECG changes decrease or disappear during exercise; this finding is unique to athlete's heart, distinguishing it from pathologic conditions. However, pseudonormalization of T-wave inversions could reflect myocardial ischemia and thus warrants further investigation in older athletes. Also, a normal exercise stress test result does not rule out a cardiomyopathy.

Table

Diagnosis references

  • 1. Brosnan MJ, Rakit D: Differentiating athlete's heart from cardiomyopathies − The left side. Heart Lung Circ 27(9):1052–1062, 2018. doi: 10.1016/j.hlc.2018.04.297

  • 2. Millar LM, Fanton Z, Finocchiaro G, et al: Differentiation between athlete's heart and dilated cardiomyopathy in athletic individuals. Heart 106(14):1059–1065, 2020. doi: 10.1136/heartjnl-2019-316147

  • 3. Czimbalmos C, Csecs I, Toth A, et al: The demanding grey zone: Sport indices by cardiac magnetic resonance imaging differentiate hypertrophic cardiomyopathy from athlete's heart. PLoS ONE 14(2): e0211624. 2019.

  • 4. Bakogiannis C, Mouselimis D, Tsarouchas A, et al: Hypertrophic cardiomyopathy or athlete's heart? A systematic review of novel cardiovascular magnetic resonance imaging parameters. Eur J Sports Sci Dec 2;1–12, 2021. doi: 10.1080/17461391.2021.2001576

  • 5. Baggish AL, Battle RW, Beaver TA, et al: Recommendations on the use of multimodality cardiovascular imaging in young adult competitive athletes: A report from the American Society of Echocardiography in collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 33 (5): 523–549, 2020. doi: 10.1016/j.echo.2020.02.009

Prognosis for Athlete’s Heart

Although gross structural changes resemble those in some cardiac disorders, generally no adverse effects are apparent. However, numerous studies have found an increased risk of developing atrial fibrillation with endurance and mixed sports. Athletes younger than 55 years are at higher risk (1 Prognosis reference Athlete’s heart is a constellation of structural and functional changes that occur in the heart of people who train for prolonged durations (eg,> 1 hour most days) and/or frequently at high... read more ). The dose of exercise at which the risk increases has not been documented in high quality studies. In most cases, structural changes and bradycardia regress with detraining, although up to 20% of elite athletes have residual chamber enlargement, raising questions, in the absence of long-term data, about whether athlete’s heart is truly benign.

Prognosis reference

Treatment of Athlete’s Heart

  • Possibly a period of deconditioning to monitor LV regression

No treatment is required, although 3 months of deconditioning may be needed to monitor LV regression as a way of distinguishing this syndrome from cardiomyopathy. Such deconditioning can greatly interfere with an athlete’s life and may meet with resistance.

Key Points

  • Intensive physical exercise increases left ventricular muscle mass, wall thickness, and chamber size but systolic function and diastolic function remain normal.

  • Resting heart rate is slow and there may be a systolic ejection murmur at the left lower sternal border, a 3rd heart sound (S3), and/or a 4th heart sound (S4).

  • ECG shows bradycardia and signs of hypertrophy and sometimes other findings such as sinus arrhythmia, atrial or ventricular ectopy, and 1st or 2nd degree atrioventricular (AV) block.

  • Structural and ECG changes due to athlete's heart are asymptomatic; the presence of cardiovascular symptoms (eg, chest pain, dyspnea, palpitations), third-degree AV block should prompt a search for an underlying cardiac disorder.

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