Athlete's heart vs cardiomyopathy
Physiological remodelling is balanced and functional; the grey zone is solved by the pattern, not one number.
Numbers to remember
- LV wall >12 mm is uncommon in athletes; 13–15 mm is the grey zone with HCM [150]
- Athlete: LV cavity usually large with normal e′; HCM: small cavity, reduced e′ [150]
- Low-normal EF in endurance athletes should rise with exercise [150]
- RV dilatation in athletes is symmetrical and without regional wall-motion abnormality [145,150]
Questions echo must answer
Intense training causes balanced enlargement of all chambers, mild wall thickening and a low resting heart rate. The EACVI/EAPC recommendations describe how to interpret echo in athletes and how to separate physiology from cardiomyopathy [150]. The question is never "is one number abnormal?". It is "is the pattern coherent with the sport, sex, ethnicity and body size, and is function normal?".
- Is it balanced?LV, RV and atria enlarged together [150].
- Is the wall thickness proportionate?Grey zone 13–15 mm [150].
- Is function normal?e′, E/e′, GLS, exercise reserve [150].
- Red flagsAsymmetry, small LV cavity, low e′, regional RV abnormalities, LGE, abnormal ECG, family history of SCD [13,14,145].
Acquisition protocol
- PLAX / PSAXIVSd, PWd, LVEDD; symmetry of hypertrophy; mitral leaflet length and SAM [150].
- ApicalLVEDV, LVEF, GLS [1].
- DiastolicE/A, e′ (usually normal or high in athletes), E/e′ [2].
- RV-focusedRV size, FAC, TAPSE, regional wall motion [3,145].
- AtriaLAVI (index to BSA; it is often enlarged in endurance athletes).
- ApexApical hypertrophy and non-compaction (contrast if needed).
- ExerciseEF reserve in borderline EF; gradients if SAM is suspected [28,150].
- ContextSport type and hours, sex, ethnicity, BSA, ECG.
- Wall thickness and symmetry
- LV cavity size
- e′ and E/e′
- LVEF and GLS
- RV size and regional motion
- LA size
- Apex (hypertrophy, trabeculation)
- Exercise reserve (if borderline EF)
Diagnosis & severity
| Feature | Favours athlete's heart | Favours cardiomyopathy |
|---|---|---|
| Wall thickness | ≤12 mm (up to ≈15 mm in some male, black athletes) | >15 mm, asymmetric [13,150] |
| LV cavity | Enlarged (LVEDD often >54 mm) | Small (HCM) or dilated with low function (DCM) |
| Diastolic function | Normal or supranormal e′ | Reduced e′, raised E/e′ |
| LVEF | Low-normal, rises with exercise | Reduced, no reserve; GLS reduced |
| RV | Symmetrical enlargement, normal regional motion | Regional akinesia or dyskinesia (ARVC) [145] |
| Detraining | Regression in 1–3 months | No regression |
| ECG | Voltage, early repolarisation | Deep T inversion, Q waves, LBBB |
| CMR | No LGE | LGE [14] |
Thresholds that change management
- Grey zone → CMR, cardiopulmonary exercise test, Holter, and genetic testing when appropriate; consider supervised detraining [14,150].
- Definite cardiomyopathy → sports participation follows the specific guideline and a shared decision [13,14].
- Low EF without exercise reserve or regional dysfunction → treat as cardiomyopathy until proved otherwise [14,150].
Pitfalls & mimics
PitfallAdolescent and female athletes rarely have walls >11–12 mm. A thickness in the grey zone for a man is abnormal for them [150].
- Index to BSA with caution: large athletes have large hearts.
- Ethnicity: black athletes show more LV hypertrophy and repolarisation changes [150].
- Anabolic steroid use produces pathological hypertrophy and reduced function.
- Hypertrabeculation is common in athletes and does not make LV non-compaction without dysfunction.