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"Athlete's heart" is a spectrum of morphological, functional, and regulatory changes that occur in people who practice regular and longterm intense physical activity. The morphological characteristics of the athlete's heart may overlap with some structural and electrical cardiac diseases that may predispose to sudden cardiac death, including inherited and acquired cardiomyopathies, aortopathies and channelopathies. Overdiagnosis should be avoided, while an early identification of underlying cardiac life-threatening disorders is essential to reduce the potential for sudden cardiac death. A step-by-step multimodality approach, including a first-line evaluation with personal and family history, clinical evaluation, 12-lead resting electrocardiography (ECG), followed by second and third-line investigations, as appropriate, including exercise testing, resting and exercise echocardiography, 24-hour ECG Holter monitoring, cardiac magnetic resonance, computed tomography, nuclear scintigraphy, or genetic testing, can be determinant to differentiate between extreme physiology adaptations and cardiac pathology. In this context, cardiovascular imaging plays a key role in detecting structural abnormalities in athletes who fall into the grey zone between physiological adaptations and a covert or early phenotype of cardiovascular disease. [ABSTRACT FROM AUTHOR]

Aims: Low QRS voltages (peak to peak <0.5 mV) in limb leads (LQRSV) on the athlete's electrocardiogram (ECG) may reflect an underlying cardiomyopathy, mostly arrhythmogenic cardiomyopathy (ACM) or non-ischaemic left ventricular scar (NILVS). We studied the prevalence and clinical meaning of isolated LQRSV in a large cohort of competitive athletes.Methods and Results: The index group included 2229 Italian competitive athletes [median age 18 years (16-25), 67% males, 97% Caucasian] without major ECG abnormalities at pre-participation screening. Three control groups included Black athletes (N = 1115), general population (N = 1115), and patients with ACM or NILVS (N = 58). Echocardiogram was performed in all athletes with isolated LQRSV and cardiac magnetic resonance (CMR) in those with ventricular arrhythmias or echocardiographic abnormalities. The isolated LQRSV pattern was found in 1.1% index athletes and was associated with increasing age (median age 28 vs. 18 years; P < 0.001), elite status (71% vs. 34%; P < 0.001), body surface area, and body mass index but not with sex, type of sport, and echocardiographic left ventricular mass. The prevalence of isolated LQRSV was 0.2% in Black athletes and 0.3% in young individuals from the general population. Cardiomyopathy patients had a significantly greater prevalence of isolated LQRSV (12%) than index athletes, Black athletes, and general population. Five index athletes with isolated LQSRV and exercise-induced ventricular arrhythmias underwent CMR showing biventricular ACM in 1 and idiopathic NILVS in 1.Conclusions: Unlike cardiomyopathy patients, the ECG pattern of isolated LQRSV was rarely observed in athletes. This ECG sign should prompt clinical work-up for exclusion of an underlying cardiomyopathy. [ABSTRACT FROM AUTHOR]

Athlete's heart is associated with physiological electrical and structural remodelling. Despite the plethora of data published on male athletes, solid data derived from female athletes, compared to male counterparts or sedentary women, are still scarce. We aimed to analyze the electrical, structural, and functional characteristics of athlete's heart in female and male athletes vs sedentary controls. Olympic athletes and sedentary controls were evaluated by resting ECG and echocardiography. Athletes were divided into 4 different sports groups. The study population included 1096 individuals (360 female athletes, 410 male athletes, 130 sedentary women and 196 sedentary men). Female athletes had lower resting heart rate, longer PR interval, higher voltage of R, and T waves and more frequently incomplete RBBB, left ventricular (LV) hypertrophy, early repolarization, and anterior T-wave inversion as compared to controls. Biventricular cavity dimensions and LV wall thickness were greater in female athletes than in female controls. However, women showed a lower degree of training-induced structural remodelling than men. In female athletes, both cavity dimensions and LV wall thickness increased from those engaged in skill and power to mixed and endurance disciplines. However, in female athletes, contrary to males, the ECG changes were not significantly different according to the different types of sport discipline. Highly-trained women demonstrate relevant training-induced electrical and structural remodelling. However, the type of sport did not influence ECG parameters in women, contrary to men, while it impacted biventricular morphologic remodelling, with endurance athletes showing the greatest degree of adaptation. • In this study, we analyzed the electrocardiographic and structural cardiac remodelling in female competitive athletes, compared with sedentary female controls and the male athletic population, with a specific focus on the impact of sports disciplines on cardiac adaptation. • The main findings of the study are: i) chronic exercise training led to significant ECG changes in female athletes as compared to age-matched sedentary controls; ii) a relevant training-induced structural heart remodelling is observed in female athletes, although of minor degree as compared to male athletes; iii) the different types of sport had in women (as in men) a different impact, with the endurance athletes showing the greatest degree of morphologic cardiac remodelling, while the extent of electrical changes are in women minimal, contrary to what observed in men. [ABSTRACT FROM AUTHOR]

Aims Endurance sports practice has significantly increased over the last decades, with a growing proportion of participants older than 40 years. Although the benefits of moderate regular exercise are well known, concerns exist regarding the potential negative effects induced by extreme endurance sport. The aim of this study was to analyse the acute effects of an ultramarathon race on the electrocardiogram (ECG), biventricular function, and ventricular arrhythmias in a population of master athletes. Methods and results Master athletes participating in an ultramarathon (50 km, 600 m of elevation gain) with no history of heart disease were recruited. A single-lead ECG was recorded continuously from the day before to the end of the race. Echocardiography and 12-lead resting ECG were performed before and at the end of the race. The study sample consisted of 68 healthy non-professional master athletes. Compared with baseline, R-wave amplitude in V1 and QTc duration were higher after the race (P  < 0.001). Exercise-induced isolated premature ventricular beats were observed in 7% of athletes; none showed non-sustained ventricular tachycardia before or during the race. Left ventricular ejection fraction, global longitudinal strain (GLS), and twisting did not significantly differ before and after the race. After the race, no significant differences were found in right ventricular inflow and outflow tract dimensions, fractional area change, s ', and free wall GLS. Conclusion  In master endurance athletes running an ultra-marathon, exercise-induced ventricular dysfunction, or relevant ventricular arrhythmias was not detected. These results did not confirm the hypothesis of a detrimental acute effect of strenuous exercise on the heart. [ABSTRACT FROM AUTHOR]

Although premature ventricular beats (PVBs) in young people and athletes are usually benign, they may rarely mark underlying heart disease and risk of sudden cardiac death during sport. This review addresses the prevalence, clinical meaning and diagnostic/prognostic assessment of PVBs in the athlete. The article focuses on the characteristics of PVBs, such as the morphological pattern of the ectopic QRS and the response to exercise, which accurately stratify risk. We propose an algorithm to help the sport and exercise physician manage the athlete with PVBs. We also address (1) which athletes need more indepth investigation, including cardiac MRI to exclude an underlying pathological myocardial substrate, and (2) which athletes can remain eligible to competitive sports and who needs to be excluded. [ABSTRACT FROM AUTHOR]

Background: Some concerns exist about possible detrimental effects on cardiac function of ultra‐endurance competitions. The aim of this study was to evaluate the acute effects of an ultramarathon by comparing pre‐ and post‐race 12‐lead ECG features. Methods: A total of 301 competitive athletes (mean age: 48 ± 9 years) running a 50‐km ultramarathon were analyzed. Twelve‐lead ECG was collected the day before the race and immediately at the finish line. According to the Italian law, athletes could have participated only after undergoing pre‐participation screening that ruled out the presence of an underlying heart disease. Results: After the race a significant increase in P‐wave voltage (P <.001) and P‐wave duration (P <.001) was found as compared to pre‐race data with a higher percentage of athletes fulfilling the ECG criteria for right atrial enlargement (RAE; from 3% to 17%, P <.001). The presence of RAE post‐race significantly correlated with age, hours of training/week, and years of training and inversely with time at the finish line and the final position in the ranking. T‐wave and R‐wave amplitude (P <.001) and QTc‐interval duration (P <.001) significantly increased after the race. No significant differences in terms of supraventricular or ventricular arrhythmias were found. Conclusions: A sizeable proportion of athletes running a 50‐km ultramarathon demonstrated post‐race ECG signs of right heart overload but no arrhythmias. This finding supports the hypothesis that ultra‐endurance races may induce transient right heart overload. [ABSTRACT FROM AUTHOR]

Aims: Twelve-lead electrocardiogram (ECG) is an established tool in the evaluation of athletes, providing information about life-threatening cardiovascular diseases, such as long QT syndrome. However, the interpretation of ECG is sometimes challenging in children, particularly for the repolarization phase. The aim of this prospective, longitudinal study was to determinate the distribution of QT interval in children practicing sport and to evaluate changes in QT duration overtime.Methods and Results: A population of 1473 preadolescents practising sport (12.0 ± 1.8 years, 7-15 years) was analysed. Each athlete was evaluated at baseline, mid-term, and end of the study (mean follow-up: 3 ± 1 years). QT interval was corrected with Bazett (B) and Fridericia (F) formulae. At baseline QT interval corrected with the Bazett formula (QTcB) was 412 ± 25 ms and QT interval corrected with the Fridericia formula (QTcF) 387 ± 21 ms, with no changes during follow-up. Ten children (0.68%) had an abnormal QTc. In those with QTcB and QTcF ≥480 ms, QTc duration persisted abnormal during the follow-up and they were disqualified. Conversely, children with 460 ms < (QTcB) <480 ms had a normal QTc interval at the end of the study. These children had also a normal QTcF. Mean difference in the calculation of QT between the two formulae was 25 ± 11 ms (P < 0.0001). For resting heart rate (HR) ≥82 b.p.m., QTcF was independent from HR contrary to QTcB.Conclusion: Normal QTc interval does not change over time in preadolescents. A minority of them has a QTc ≥480 ms; in these subjects, QTc interval remains prolonged. The use of Bazett and Fridericia correction formulae is not interchangeable and the Fridericia correction should be preferred in preadolescents with a resting HR ≥82 b.p.m. [ABSTRACT FROM AUTHOR]

Abstract Background T-wave inversion (TWI) is rare in athlete's heart but is a common manifestation in cardiomyopathies. Although TWI has been extensively investigated in adult athletes, the ability of this ECG pattern to distinguish between a physiological variant and a developing heart muscle disease in children is controversial. The aim of this longitudinal study was to establish the prevalence, changes and clinical significance of TWI in a large cohort of pre-adolescent athletes. Methods 2227 children (mean age 12.3 ± 2.0 years) undergoing sports preparticipation screening were included. Children with TWI underwent yearly follow-up until the positivisation of TWI for a maximum follow-up of 4 years. Results Among 2227 children, 358 (16%) had TWI. Children with TWI were younger (11.4 ± 2.1 vs. 12.5 ± 2.0 years, p < 0.0001) and had a lower BSA than children without TWI (p < 0.0001). 97% of children showed anterior TWI while only 3% had infero-lateral TWI. Anterior TWI became positive in 94% of children during the 4-year follow-up (p < 0.0001 vs. baseline) and the remaining 6% did not show abnormal clinical findings. Conversely, in the group of 9 children with infero-lateral TWI, only 1 showed normalisation during follow-up (p = 0.81) and 1 was found to have a cardiomyopathy. Conclusions Anterior TWI is common in children and generally becomes positive by the age of 14 years. Conversely, infero-lateral TWI is rare, persistent and may be associated with structural heart disease. Therefore, infero-lateral TWI should not be interpreted as physiologically related to age, development or training and children with infero-lateral TWI should remain under strict clinical surveillance. Highlights • This study establishes the prevalence of TWI in a large cohort of children practising sport • This longitudinal study demonstrates that anterior TWI usually becomes positive by the age of 14 years • Conversely, children with infero-lateral TWI followed for 4 years did not demonstrate significant changes in the ECG pattern • Infero-lateral TWI should not be interpreted as physiologically related to age, development or training • This study support the concept that children with infero-lateral TWI should remain under strict clinical surveillance [ABSTRACT FROM AUTHOR]

Aims Little is known about the adaptation of the right ventricle (RV) to endurance exercise in children. The aim of this study was to assess the effects of 5 months of intensive training on RV morphology and function in preadolescent endurance athletes. Methods Ninety-four children were evaluated in this study. Fifty-seven male competitive swimmers (aged 10.8 ± 0.2 years) were evaluated before (baseline) and after 5 months of the training (peak-training), and compared to 37 age- and sex-matched non-athlete children evaluated at baseline and after 5 months of natural growth. All subjects were asymptomatic, with negative family history for cardiomyopathies. Results At baseline no differences were found between athletes and controls for indexed RV outflow tract (RVOT) (18.5 ± 2.7 vs. 16.8 ± 5.0 mm/m 2 , p = 0.18) and RV basal end-diastolic diameter (EDD) (24.9 ± 4.1 vs. 23.6 ± 3.0 mm/m 2 , p = 0.15). After 5 months, indexed RVOT and RV basal EDD significantly increased in athletes (20.2 ± 2.9 mm/m 2 and 25.4 ± 3.3 mm/m 2 , p < 0.0001 vs. baseline) while no differences were observed in controls ( p = 0.84 and p = 0.25). Despite the increase in RV size, RV function remained normal in athletes, with no changes in RV fractional area change ( p = 0.97), s′ value ( p = 0.22), and RV longitudinal strain ( p = 0.28). Conclusions Endurance training influences the growing heart of male preadolescent athletes with an addictive increase in RV dimensions, with a preserved RV function. Therefore, in children engaged in endurance sports the increase in RV size associated with normal RV function represents a physiological expression of the athlete's heart and should not be misinterpreted as an expression of incipient RV cardiomyopathy. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to assess the impact of sex and different sports on right ventricular (RV) remodeling and compare the derived upper limits with widely used revised Task Force (TF) reference values. Background Uncertainties exist regarding the extent and physiological determinants of RV remodeling in highly trained athletes. The issue is important, considering that in athletes RV size occasionally exceeds the cutoff limits proposed to diagnose arrhythmogenic RV cardiomyopathy. Methods A total of 1,009 Olympic athletes (mean age 24 ± 6 years; n = 647 [64%] males) participating in skill, power, mixed, and endurance sport were evaluated by 2-dimensional echocardiography and Doppler/tissue Doppler imaging. The right ventricular outflow tract (RVOT) in parasternal long-axis (PLAX) and short-axis views, fractional area change, sʹ velocity, and morphological features were assessed. Results Indexed RVOT PLAX was greater in females than in males (15.3 ± 2.2 mm/m 2 vs. 14.4 ± 1.9 mm/m 2 ; p < 0.001). Both RVOT PLAX and parasternal short-axis view were significantly different among skill, power, mixed, and endurance sports: 14.3 ± 2.1 mm/m 2 versus 14.7 ± 1.9 mm/m 2 versus 14.0 ± 1.8 mm/m 2 versus 15.7 ± 2.2 mm/m 2 , respectively (p < 0.001); and 15.2 ± 2.7 mm/m 2 versus 15.3 ± 2.4 mm/m 2 versus 14.8 ± 2.1 mm/m 2 versus 16.2 ± 2.5 mm/m 2 , respectively (p < 0.001). The 95th percentile for indexed RVOT PLAX and parasternal short-axis view was 18 mm/m 2 and 20 mm/m 2 , respectively. Fractional area change and sʹ velocity did not differ among the groups (p = 0.34 for both). RV enlargement compatible with major and minor TF diagnostic criteria for arrhythmogenic RV cardiomyopathy was observed in 41 (4%) and 319 (32%) athletes. A rounded apex was described in 823 (81%) athletes, prominent trabeculations in 378 (37%) athletes, and a prominent/hyperreflective moderator band in 5 (0.5%) athletes. Conclusions RV remodeling occurs in Olympic athletes, with male sex and endurance practice playing the major impact. A significant subset (up to 32%) of athletes exceeds the normal TF limits; therefore, we recommend referring to the 95th percentiles here reported as referral values; alternatively, only major diagnostic TF criteria for arrhythmogenic RV cardiomyopathy may be appropriate. [ABSTRACT FROM AUTHOR]

Two-dimensional (2D) speckle-tracking echocardiography (STE) has clarified functional adaptations accompanying the morphological features of 'athlete's heart'. However, 2D STE has some limitations, potentially overcome by three-dimensional (3D) STE. Unfortunately, discrepancies between 2D- and 3D STE have been described. We therefore sought to evaluate whether dimensional and functional differences exist between athletes and controls and whether 2D and 3D left ventricular (LV) strains differ in athletes. One hundred sixty-one individuals (91 athletes, 70 controls) were analysed. Athletes were members of professional sports teams. 2D and 3D echocardiography and STE were used to assess LV size and function. Bland-Altman analysis was used to estimate the level of agreement between 2D and 3D STE. Athletes had greater 2D and 3D-derived LV dimensions and LV mass (p < 0.0001 for all), while 2D- and 3D-derived LV ejection fraction did not differ as compared with controls (p = 0.82 and p = 0.89, respectively). Longitudinal, radial, and circumferential strains did not differ between athletes and controls, neither by 2D nor by 3D STE. Three-dimensional longitudinal and circumferential strain values were lower (p < 0.0001 for both) while 3D radial strain was greater, as compared with 2D STE (p < 0.001). Bland-Altman plots demonstrated the presence of an absolute systematic error between 2D and 3D STE to analyse LV myocardial deformation. 3D STE is a useful and feasible technique for the assessment of myocardial deformation with the potential to overcome the limitations of 2D imaging. However, discrepancies exist between 2D and 3D-derived strain suggesting that 2D and 3D STE are not interchangeable. [ABSTRACT FROM AUTHOR]

Aims Previous studies investigated the exercise-induced adaptation of left (LA) and right atrium (RA) in adults, but little is known about respective changes in the growing heart of children. We aimed to longitudinally investigate the effects of endurance training on biatrial remodelling in preadolescent athletes. Methods and results Ninety-four children (57 endurance athletes, 37 sedentary controls; mean age 10.8 ± 0.2 and 10.2 ± 0.2 years, respectively) were evaluated at baseline and after 5 months by ECG and by two-dimensional, three-dimensional (3D) and speckle-tracking echocardiography. Athletes were trained at least 10 h/week. The resting heart rate was lower in athletes ( p = 0.046) and decreased further after training ( p < 0.0001). Neither athletes nor controls had ECG evidence for LA or RA enlargement. At baseline, indexed LA volumes did not differ between groups ( p = 0.14) but indexed RA dimensions were larger in athletes ( p = 0.007). After 5 months, indexed LA volumes increased in athletes but not in controls ( p < 0.0001, p = 0.29; respectively) while indexed RA volumes increased in both groups (p < 0.0001, p = 0.018; respectively). At the same time, slight differences in biatrial reservoir and contractile function were found either in athletes, as demonstrated by speckle-tracking echocardiography, but 3D-derived LA and RA ejection fraction remained stable in both groups. Conclusion Endurance training influences the growing heart of preadolescent athletes with an additive increase in biatrial size, suggesting that morphological adaptations can occur also in the early phases of the sports career. Training-induced remodelling was associated with a preserved biatrial function, supporting the hypothesis of a physiological remodelling. [ABSTRACT FROM AUTHOR]

Aims Conflicting evidence exists concerning right ventricular (RV) morphological and functional remodelling in trained athletes, with a very few longitudinal data prospectively investigating the RV changes. The aim of this study was to assess the morphological and functional RV changes occurring during the competitive season in young athletes engaged in the most popular team sports. Methods and results Twenty-nine top-level athletes (age: 20.9 ± 6.7 years), practicing basketball and volleyball, were evaluated at pre-season, mid-season, and end-season time-points, using tissue Doppler imaging and 2D speckle-tracking echocardiography. RV basal and mid-cavity end-diastolic diameters (EDDs; overall P = 0.011 and P < 0.0001, respectively), and RV diastolic area (overall P < 0.0001) increased during the season. Conversely, RV outflow tract did not vary (overall P = 0.96). During the season, no significant differences were observed in RV diastolic functional indexes and in RV fractional area change (overall P = 0.35). Global RV longitudinal strain did not significantly change (overall P = 0.52), although apical longitudinal strain significantly increased (overall P = 0.017). In association, left ventricular (LV) volume and mass increased during the season (overall P = 0.007). On multivariate analysis, LV mass was the only independent predictor of RVEDD at pre-season (β = 0.69, P < 0.0001) and at end-season (β = 0.82, P < 0.0001). Conclusions Right ventricular chamber size increases during the competitive season in top-level athletes, with no significant changes in the outflow tract. RV morphological adaptation in top-level athletes practicing team sports is not associated with a reduction in RV function or in myocardial deformation and occurs in close association with changes on the left ventricle, suggesting a physiological remodelling of the right ventricle. [ABSTRACT FROM AUTHOR]

Biatrial enlargement is common in athletes with a further increase occurring after training. P-wave morphology seems to be unaffected by atrial size, however longitudinal data are not available. This study aimed to prospectively investigate whether exercise-induced increase in biatrial size corresponds to electrical changes on 12-lead ECG. Thirty-five athletes were evaluated at the beginning of the training and after 6 months by ECG and standard and speckle-tracking echocardiography. Twenty-three sedentary subjects served as controls. Athletes had greater left atrial (LA) and right atrial (RA) size compared with controls (20.7 ± 4.7 vs. 27.1 ± 6.6 and 17.3 ± 3.8 vs. 23.4 ± 6.3 mL/m2, respectively, p < 0.0001). After 6 months, a further increase in LA and RA size was observed (p < 0.0001 and p = 0.002, respectively). Neither athletes nor controls fulfilled the ECG criteria for RA enlargement and no differences were found for LA enlargement criteria between athletes and controls (2/35, 6% vs. 0/23, 0%, p = 0.23). This percentage remained unchanged after training. Biatrial stiffness remained normal in athletes also after training. Training causes an increase in biatrial volumes, with normal filling pressures and normal stiffness. These changes in atrial morphology are not associated with respective electrical changes, suggesting that P-wave morphology is unaffected by training-induced biatrial dilatation in young healthy athletes. [ABSTRACT FROM AUTHOR]

Purpose: Although left atrial (LA) enlargement is a recognized component of athlete's heart, dynamic cavity changes occurring during the training period remain to be elucidated. We aimed to investigate the adaptive changes of LA reservoir, conduit, and active volumes in elite athletes vs. controls and their response to different training loads. Methods: LA maximum, pre-P, and minimum volumes were assessed in 26 top-level athletes and 23 controls. In athletes, LA volumes were measured at pre-, mid-, end-training, and post-detraining time points using conventional 2D echocardiography. Results: Athletes had larger maximum (27.5 ± 3.2 vs. 20.3 ± 5.8 mL/m, p = 0.001), pre-P (11.5 ± 0.9 vs. 9.8 ± 2.2 mL/m, p = 0.001), and minimum (6.6 ± 0.9 vs. 5.0 ± 1.2 mL/m, p < 0.001) LA indexed volumes, compared with controls. Total and passive emptying volume indices were also larger in athletes compared with controls (18.7 ± 3.1 vs. 15.3 ± 4.9 mL/m, p < 0.05 and 13.8 ± 2.9 vs. 10.5 ± 4.6 mL/m, p < 0.05, respectively), while active emptying volume was similar ( p = 0.74). During training, LA maximum ( p < 0.0001), pre-P ( p < 0.0001), minimum ( p < 0.0001), total ( p < 0.005), and passive ( p < 0.05) emptying volume indices progressively increased, while active emptying volume ( p = 0.10) and E/e′ ratio ( p = 0.32) remained unchanged. After detraining, LA volume measurements were not different from pre-training ones. End-training left ventricular mass index was the only independent predictor of the respective maximum LA volume (β = 0.74, p < 0.005). Conclusions: Top-level athletes exhibit a dynamic morphological and functional LA remodeling, induced by training, with an increase in reservoir and conduit volumes, but stable active volume. LA remodeling is closely associated with left ventricular adaptation to exercise and both completely regress after detraining. [ABSTRACT FROM AUTHOR]

Background Heart rate variability ( HRV) has been rarely applied in elite athletes prior to competition. The aim of this study was to examine the changes in HRV in elite female volleyball players before a stressful match during play offs and to evaluate the impact on sport-specific performance. Methods A short-term resting HRV analysis was applied right after the night sleep in ten female athletes 1 and 2 days prior to the match and the day of the competition. Results Approaching the decisive match, RR interval, resting heart rate ( HR), p NN50, r MSDD and SD1 did not significantly vary. SD2 significantly increased in comparison with first-day measurement ( P<0·05). HF% levels significantly decreased the prematch day and the match day ( P<0·05); however, no significant changes in LF/ HF% ratio were observed. A gradual increase in VLF% and in Ln VLF was observed, with a significant difference between first-day and match-day measurements ( P<0·01 and P<0·05, respectively). The number of positive receptions was inversely correlated with LF/ HFms2 ratio, with LF/ HF% ratio ( R = −0·98, P<0·05 for both) and with resting HR ( R = −0·92, P<0·05). Conclusions Elite female athletes practising team sports exhibit a slight change in HRV prior to a decisive competition, without a pronounced variation of the autonomic nervous system activity. A day-to-day HRV measurement could be a useful tool to evaluate the impact of a competition on the autonomic nervous system in athletes, also considering the relationship between sympathetic activity and athletic performance. [ABSTRACT FROM AUTHOR]

Background. Endurance sports practice has significantly increased over the last decades, with a growing proportion of master athletes. However, concerns exist regarding the potential proarrhythmic effects induced by ultra-endurance sports. This study aimed to analyse the acute effects of an ultramarathon race on atrial remodelling and supraventricular arrhythmias in a population of master athletes. Methods. Master athletes participating in an ultramarathon (50 km, 600 m of elevation gain) with no history of heart disease were recruited. A single-lead ECG was recorded continuously from the day before to the end of the race. Echocardiography and 12-lead resting ECG were performed before and immediately at the end of the race. Results. The study sample consisted of 68 healthy non-professional master athletes. Compared with baseline, P wave voltage was higher after the race (p < 0.0001), and more athletes developed ECG criteria for right atrial enlargement (p < 0.0001). Most of the athletes (97%) had ≥1 premature atrial beats (PAB) during the 24-h monitoring, also organised in triplets (17%) and non-sustained supraventricular tachycardias (NSSVTs) (19%). In contrast, exercise-induced PABs, triplets, and NSSVTs were rare. One athlete developed acute atrial fibrillation during the race. After the race, no significant differences were found in biatrial dimensions. Biatrial function, estimated by peak atrial longitudinal and contraction strains, were normal both before and after the race. Conclusions. In master athletes running an ultramarathon, acute exercise-induced atrial dysfunction was not detected, and exercise-induced supraventricular arrhythmias were uncommon. These results did not confirm the hypothesis of an acute atrial dysfunction induced by ultra-endurance exercise. [ABSTRACT FROM AUTHOR]

Although many echocardiographic studies are available about the adaptation of left ventricle to intensive training, right heart function has been poorly investigated and no data are available about the right atrial (RA) function in top-level athletes. The aim of the study was to investigate RA function and dimension by standard echocardiography and 2D speckle tracking echocardiography (STE). One hundred top-levels athletes were recruited from professional sports team and were compared with 78 normal subjects. Athletes during an off-training period or during prolonged forced rest resulting from injuries were excluded. Top-level athletes had higher BSA as compared with controls and, as expected, a lower resting heart rate ( p ≤ 0.001). RA area, volume, and volume index were significantly greater in athletes than in controls ( p ≤ 0.001). This increase was associated with greater right ventricular and inferior vena cava diameters ( p ≤ 0.001). Peak atrial longitudinal strain and peak atrial contraction strain values were significantly lower in athletes in comparison with controls (40.92 ± 9.86 % vs. 48.00 ± 12.68 %, p ≤ 0.001; 13.05 ± 4.84 % vs. 15.99 ± 5.74 %, p ≤ 0.001, respectively). Interestingly, while athletes presented a higher E/A ratio ( p ≤ 0.001) and a lower peak A velocity ( p ≤ 0.001), the E/e′ ratio did not differ between the two groups. In top-level athletes the RA presents a physiological adaptation to intensive exercise conditioning which determines not only a morphological but also a functional remodeling. We reported for the first time reference values of RA strain in elite athletes, demonstrating that 2D STE is a useful tool to investigate RA longitudinal myocardial deformation dynamics in athlete's heart. [ABSTRACT FROM AUTHOR]

"Athlete's heart" is a spectrum of morphological and functional changes which occur in the heart of people who practice physical activity. When athlete's heart occurs with its most marked expression, it may overlap with a differential diagnosis with certain structural cardiac diseases, including cardiomyopathies, valvular diseases, aortopathies, myocarditis, and coronary artery anomalies. Identifying the underlying cardiac is essential to reduce the potential for sudden cardiac death. For this purpose, a spectrum of imaging modalities, including rest and exercise stress echocardiography, speckle tracking echocardiography, cardiac magnetic resonance, computed tomography, and nuclear scintigraphy, can be undertaken. The objective of this review article is to provide to the clinician a practical step-by-step approach, aiming at distinguishing between extreme physiology and structural cardiac disease during the athlete's cardiovascular evaluation. [ABSTRACT FROM AUTHOR]

Anomalous aortic origin of coronary arteries (AAOCA) represents a rare congenital heart disease. However, this disease is the second most common cause of sudden cardiac death in apparently healthy athletes. The aim of this systematic review is to analyze the feasibility and the detection rate of AAOCA by echocardiography in children and adults. A literature search was performed within the National Library of Medicine using the following keywords: coronary artery origin anomalies and echocardiography; then, the search was redefined by adding the keywords: athletes, children, and high take-off. Nine echocardiographic studies investigating AAOCA and a total of 33,592 children and adults (age range: 12–49 years) were included in this review. Of these, 6599 were athletes (12–49 years). All studies demonstrated a high feasibility and accuracy of echocardiography for the evaluation of coronary arteries origin as well as their proximal tracts. However, some limitations exist: the incidence of AAOCA varied from 0.09% to 0.39% (up to 0.76%) and was lower than described in computed tomography series (0.3–1.8%). Furthermore, echocardiographic views for the evaluation of AAOCA and the definition of "minor" defects (e.g., high take-off coronary arteries) have not been standardized. An echocardiographic protocol to diagnose the high take-off of coronary arteries is proposed in this article. In conclusion, the screening of AAOCA by echocardiography is feasible and accurate when appropriate examinations are performed; however, specific acoustic windows and definitions of defects other than AAOCA need to be standardized to improve sensitivity and specificity. [ABSTRACT FROM AUTHOR]

Arterial hypertension (AH) is one of the most common pathologic conditions and uncontrolled AH is a leading risk factor for cardiovascular disease and mortality. AH chronically causes myocardial and arterial remodelling with hemodynamic changes affecting the heart and other organs, with potentially irreversible consequences leading to poor outcomes. Therefore, a proper and early treatment of AH is crucial after the diagnosis. Beyond medical treatment, physical exercise also plays a therapeutic role in reducing blood pressure, given its potential effects on sympathetic tone, renin-angiotensin-aldosterone system, and endothelial function. International scientific societies recommend physical exercise among lifestyle modifications to treat AH in the first stages of the disease. Moreover, some studies have also shown its usefulness in addition to drugs to reduce blood pressure further. Therefore, an accurate, personalized exercise prescription is recommended to optimize the prevention and treatment of hypertension. On the other hand, uncontrolled AH in athletes requires proper risk stratification and careful evaluation to practice competitive sports safely. Moreover, the differential diagnosis between hypertensive heart disease and athlete's heart is sometimes challenging and requires a careful and comprehensive interpretation in order not to misinterpret the clinical findings. The present review aims to discuss the relationship between hypertensive heart disease and physical exercise, from diagnostic tools to prevention and treatment strategies. • Arterial hypertension (AH) is the most prevalent cardiovascular risk factor. • Differential diagnosis of hypertensive heart disease requires a multiparametric evaluation. • Physical exercise is recommended among lifestyle modifications to treat AH. • Combining drugs with PE offers additive value for the reduction of blood pressure. • AH diagnosis and good blood pressure control is essential for safe sports practice. [ABSTRACT FROM AUTHOR]

Background: Postexercise release of cardiac troponin (cTn) is a well-known phenomenon, although the influence of various confounders remains unclear. The aim of this critical review was to analyze the postexercise release of cTn according to age, sex, different types of sport, exercise intensity and duration, and training level. Data Sources: A literature search was performed within the National Library of Medicine using the following keywords: cTn, peak, release, and exercise. The search was further refined by adding the keywords athletes, children/adolescents, and sport. Main Results: For final analysis, 52 studies were included: 43 adult studies, 4 pediatric studies, and 5 with a mixed population of adults and children. Several studies have investigated the kinetics of cTn response after exercise with different biomarkers. The current evidence suggests that sport intensity and duration have significant effects on postexercise cTn elevation, whereas the influence of the type of sport, age, and sex have been not completely defined yet. Most data were obtained during endurance races, whereas evidence is limited (or almost absent), particularly for mixed sports. Data on young adults and professional athletes are limited. Finally, studies on women are extremely limited, and those for non-White are absent. Conclusions: Postexercise release of cTn can be observed both in young and master athletes and usually represents a physiological phenomenon; however, more rarely, it may unmask a subclinical cardiac disease. The influence of different confounders (age, sex, sport type/intensity/duration, and training level) should be better clarified to establish individualized ranges of normality for postexercise cTn elevation. [ABSTRACT FROM AUTHOR]

Premature ventricular beats (PVBs) are not an unusual finding and their interpretation is sometimes challenging. Unfortunately, few data on the characteristics of PVBs that correlate with the risk of an underlying heart disease are available in athletes. The aim of this prospective study was to investigate the diagnostic and prognostic value of PVBs characteristics in competitive athletes. From a cohort of 1751 athletes evaluated at our sports cardiology centre, we enrolled 112 competitive athletes <40 years of age (mean age 21 ± 10 years) and with no known heart disease referred for PVBs. All athletes underwent physical examination, ECG, 12‑lead ambulatory ECG monitoring, exercise testing, and echocardiography. Further investigations including cardiac magnetic resonance were performed for abnormal findings at first-line evaluation or for specific PVBs characteristics. The majority (79%) of athletes exhibited monomorphic PVBs with a fascicular or infundibular pattern (common morphologies). A definitive diagnosis of cardiac disease was reached in 26 athletes (23% of the entire population) and correlated with uncommon PVBs morphology (p < 0.001) and arrhythmia complexity (p < 0.001). The number of PVBs/24-h was lower in athletes with cardiac disease than in those with normal heart (p < 0.05). During the follow-up a spontaneous reduction of PVBs and no adverse events were observed. Infundibular and fascicular PVBs were the most common morphologies observed in athletes with ventricular arrhythmias referred for cardiological evaluation. Morphology and complexity of PVBs, but not their number, predicted the probability of an underlying disease. Athletes with PVBs and negative investigation showed a good prognosis. • PVBs' morphology may help distinguishing between benign and malignant PVBs • Morphology and complexity of PVBs predict the probability of an underlying disease • The number of PVBs does not predict the probability of an underlying disease • Uncommon PVBs morphologies are associated with structural heart disease • Common PVBs patterns can be found also in athletes with normal heart [ABSTRACT FROM AUTHOR]

The athlete's heart is a well-known phenomenon characterized by a harmonic remodelling that affects the cardiac chambers. However, whether mild-to-moderate aortic dilatation can be considered normal in athletes is debated. This study aimed to evaluate the ratio between left ventricular (LV) size and aortic dimensions, reporting the normal values of the ratio between the aortic root diameters at the level of the sinuses of Valsalva and LV diameters (AoD/LVEDD ratio) in a wide cohort of competitive athletes. Competitive athletes were compared with sedentary subjects and patients with aortic dilatation. 1901 subjects who underwent echocardiography from 2019 to 2022 were retrospectively enrolled: 993 athletes (74% males, mean age 26 ± 7 years), 410 sedentary (74.1% males, mean age 29 ± 11 years) and 498 patients with aortic dilatation (74.3% males, mean age 56 ± 7 years). Patients with aortic dilatation had both an absolute (39.2 ± 2.4 mm) and indexed (19.4 ± 2.2 mm/m2) aortic diameter larger than athletes (30.6 ± 3.2 mm; 16.1 ± 1.5 mm/m2, p < 0.05) and sedentary subjects (30.5 ± 3.1 mm; 16.5 ± 1.6 mm/m2, p < 0.05), with no differences between athletes and sedentary subjects. The AoD/LVEDD ratio was lower in athletes (0.59 ± 0.06) compared to controls (0.65 ± 0.05, p < 0.05) and patients with aortic dilatation (0.81 ± 0.06, p < 0.05). The patients with aortopathy had the lowest LVEDD/AoD ratio, while competitive athletes had the highest, with values of 1.71 ± 0.16 in the latter (overall p value<0.001). In this study, we reported the AoD/LVEDD and LVEDD/AoD ratio values in a cohort of healthy athletes, additional parameters that could help confirm the harmonic remodelling in the athlete's heart. • intensive and regular training is not accompanied by a significant remodelling of the aorta. • a simple 'golden' ratio between the AoD and LVEDD can help to evaluate a physiological exercise-induced remodelling. • a peculiar training-induced remodelling of the aorta exists according to the type of sports disciplines practised. [ABSTRACT FROM AUTHOR]