Cardiovascular Considerations in Athletes

Introduction to Athlete's Heart

Athlete's heart is a benign physiological adaptation to regular intense exercise that typically requires no specific treatment beyond appropriate monitoring and screening, according to the European Society of Cardiology 1, 2

A systematic diagnostic approach for athlete's heart includes initial evaluation with 12-lead ECG, detailed personal and family history, physical examination, and echocardiography, and advanced imaging such as cardiac MRI or CT angiography when initial evaluation is inconclusive 2
The European Society of Cardiology recommends a comprehensive evaluation to exclude underlying pathology, including history and physical examination, echocardiography, exercise testing, and 24-hour Holter monitoring, for athletes with premature ventricular beats (PVBs) 2

Training-related ECG changes include sinus bradycardia, first-degree AV block, early repolarization, and voltage criteria for LV hypertrophy, which should be distinguished from pathological findings such as ST-segment depression, T-wave inversion, and pathologic Q waves, as recommended by the European Society of Cardiology 1
Black athletes may exhibit T-wave inversions in V1-V4 with ST-segment elevation as a normal variant, according to the European Society of Cardiology 1
Symmetric left ventricular hypertrophy (typically <12mm in Caucasians), balanced chamber enlargement, and normal or enhanced diastolic function are characteristic of athlete's heart, as described by the European Society of Cardiology 1
Relative wall thickness between 0.30-0.45 is also typical of athlete's heart, according to the European Society of Cardiology 1

Findings favoring athlete's heart include enlarged LV cavity (>54mm), normal LV geometry, normal diastolic function, symmetric wall thickening, and regression of hypertrophy after 3 months of detraining, as recommended by the European Society of Cardiology 1
Findings favoring hypertrophic cardiomyopathy (HCM) include family history of sudden cardiac death/HCM, major ECG abnormalities, normal or reduced LV cavity size (<54mm), abnormal LV geometry or segmental hypertrophy, and abnormal diastolic function, according to the European Society of Cardiology 1
Cardiac MRI with late gadolinium enhancement (LGE) can help differentiate athlete's heart from pathological conditions, with absence of LGE favoring athlete's heart, as described by the European Society of Cardiology 1
Exercise echocardiography can also help differentiate athlete's heart from pathological conditions, with normal augmentation of systolic function with exercise favoring athlete's heart, according to the European Society of Cardiology 1

No specific treatment is required for athlete's heart, and continued participation in sports is permitted, with regular cardiovascular screening as per athletic protocols, as recommended by the European Society of Cardiology 1
Consider temporary detraining (3 months) to assess regression of LV hypertrophy, and follow-up imaging studies annually, according to the European Society of Cardiology 1
Athletes with repolarization abnormalities without structural heart disease should undergo regular follow-up imaging, with annual echocardiography typically sufficient, as recommended by the European Society of Cardiology 1, 2

Black athletes exhibit more pronounced LV hypertrophy (up to 16mm) compared to white athletes (up to 15mm), and higher prevalence of ECG anomalies, as described by the European Society of Cardiology 1
Female athletes typically show less pronounced cardiac remodeling, with upper limit of LV wall thickness being 11mm in white females and 13mm in black females, according to the European Society of Cardiology 1
Athletes with anomalous origin of coronary arteries should be restricted from participation in competitive sports until surgical repair, as recommended by the American Heart Association 3
Athletes with left ventricular hypertrophy beyond that expected for athlete's heart should limit participation until blood pressure is normalized with drug therapy, as recommended by the American Academy of Pediatrics 4
Child and adolescent athletes with LVH should be managed by pediatric cardiologists, according to the American Academy of Pediatrics 4

Premature ventricular beats (PVBs) are common in athletes and are generally benign in the absence of structural heart disease, as stated by the European Heart Rhythm Association 2
Athletes with WPW syndrome and documented symptomatic paroxysmal AV re-entry tachycardia should be considered for ablation, according to the European Heart Rhythm Association 2
Athletes with atrial flutter can participate in competitive sports after successful catheter ablation and absence of arrhythmia recurrence for >3 months, as recommended by the European Heart Rhythm Association 2