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Aims: To compare (1) conventional left ventricular (LV) functional parameters, (2) LV peak strain and strain rate and (3) LV temporal strain and strain rate curves in age, ethnicity and sport-matched athletes with concentric, eccentric and normal LV geometry. Methods: Forty-five male athletes were categorised according to LV geometry including concentric remodelling/hypertrophy (CON), eccentric hypertrophy (ECC) or normal (NORM). Athletes were evaluated using conventional echocardiography and myocardial speck tracking, allowing the assessment of myocardial strain and strain rate; as well as twist mechanics. Results: Concentric remodelling was associated with an increased ejection fraction (EF) compared to normal geometry athletes (64% (48–78%) and 56% (50–65%), respectively; p < 0.04). No differences in peak myocardial strain or strain rate were present between LV geometry groups including global longitudinal strain (GLS; CON −16.9% (−14.9–20.6%); ECC −17.9% (−13.0–22.1%); NORM −16.9% (−12.8–19.4%)), global circumferential strain (GCS; CON −18.1% (−13.5–24.5%); ECC −18.7% (−15.6–22.4%); NORM −18.0% (−13.5–19.7%)), global radial strain (GRS; CON 42.2% (30.3–70.5%); ECC 50.0% (39.2–60.0%); NORM 40.6 (29.9–57.0%)) and twist (CON 14.9° (3.7–25.3°); ECC 12.5° (6.3–20.8°); NORM 13.2° (8.8–24.2°)). Concentric and eccentric remodelling was associated with alterations in temporal myocardial strain and strain rate as compared to normal geometry athletes. Conclusion: Physiological concentric and eccentric remodelling in the athletes heart is generally associated with normal LV function; with concentric remodelling associated with an increased EF. Physiological concentric and eccentric remodelling in the athletes heart has no effect on peak myocardial strain but superior deformation and untwisting is unmasked when assessing the temporal distribution.

Transthoracic echocardiography (TTE) is widely utilised within many aspects of clinical practice, as such the demand placed on echocardiography services is ever increasing. In an attempt to provide incremental value for patients and standardise patient care, the British Society of Echocardiography in collaboration with the British Heart Valve Society have devised updated guidance for the indications and triaging of adult TTE requests for TTE services to implement into clinical practice.

The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor (EGF) receptor (HER) 2-positive targeted treatment (e.g. trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.

More than 300 000 procedures are performed in cardiac catheter laboratories in the UK each year. The variety and complexity of percutaneous cardiovascular procedures have both increased substantially since the early days of invasive cardiology, when it was largely focused on elective coronary angiography and single chamber (right ventricular) permanent pacemaker implantation. Modern-day invasive cardiology encompasses primary percutaneous coronary intervention, cardiac resynchronisation therapy, complex arrhythmia ablation and structural heart interventions. These procedures all carry the risk of cardiac arrest.We have developed evidence-based guidelines for the management of cardiac arrest in adult patients in the catheter laboratory. The guidelines include recommendations which were developed by collaboration between nine professional and patient societies that are involved in promoting high-quality care for patients with cardiovascular conditions. We present a set of protocols which use the skills of the whole catheter laboratory team and which are aimed at achieving the best possible outcomes for patients who suffer a cardiac arrest in this setting. We identified six roles and developed a treatment algorithm which should be adopted during cardiac arrest in the catheter laboratory. We recommend that all catheter laboratory staff undergo regular training for these emergency situations which they will inevitably face.

Since cardiac ultrasound was introduced into medical practice around the middle twentieth century, transthoracic echocardiography has developed to become a highly sophisticated and widely performed cardiac imaging modality in the diagnosis of heart disease. This evolution from an emerging technique with limited application, into a complex modality capable of detailed cardiac assessment has been driven by technological innovations that have both refined ‘standard’ 2D and Doppler imaging and led to the development of new diagnostic techniques. Accordingly, the adult transthoracic echocardiogram has evolved to become a comprehensive assessment of complex cardiac anatomy, function and haemodynamics. This guideline protocol from the British Society of Echocardiography aims to outline the minimum dataset required to confirm normal cardiac structure and function when performing a comprehensive standard adult echocardiogram and is structured according to the recommended sequence of acquisition. It is recommended that this structured approach to image acquisition and measurement protocol forms the basis of every standard adult transthoracic echocardiogram. However, when pathology is detected and further analysis becomes necessary, views and measurements in addition to the minimum dataset are required and should be taken with reference to the appropriate British Society of Echocardiography imaging protocol. It is anticipated that the recommendations made within this guideline will help standardise the local, regional and national practice of echocardiography, in addition to minimising the inter and intra-observer variation associated with echocardiographic measurement and interpretation.

Hypertrophic cardiomyopathy (HCM) is common, inherited and characterised by unexplained thickening of the myocardium. The British Society of Echocardiography (BSE) has recently published a minimum dataset for transthoracic echocardiography detailing the core views needed for a standard echocardiogram. For patients with confirmed or suspected HCM, additional views and measurements are necessary. This guideline, therefore, supplements the minimum dataset and describes a tailored, stepwise approach to the echocardiographic examination, and echocardiography's position in the diagnostic pathway, before advising on the imaging of disease complications and invasive treatments.

Background:Echocardiographic evaluation of left ventricular ejection fraction (LVEF) is used in the risk stratification of patients with an acute myocardial infarction (AMI). However, the prognostic value of the Tei index, an alternative measure of global cardiac function, in AMI patients is not well established. Methods:We conducted a systematic review, using MEDLINE and EMBASE, to evaluate the prognostic value of the Tei index in predicting adverse outcomes in patients presenting with AMI. The data was collected and narratively synthesised. Results:A total of 16 studies were including in this review with 2886 participants (mean age was 60 years from 14 studies, the proportion of male patients 69.8% from 14 studies). Patient follow-up duration ranged from during the AMI hospitalisation stay to 57.8 months. Tei index showed a significant association with heart failure episodes, reinfarction, death and left ventricular thrombus formation in 14 out of the 16 studies. However, in one of these studies, Tei index was only significantly predictive of cardiac events in patients where LVEF was Conclusion:Tei index may be an important prognostic marker in AMI patients, however, more studies are needed to better understand when it should be used routinely within clinical practice

Introduction Chest pain is one of the most common reasons for emergency hospital admission. The Manchester Acute Coronary Syndrome (MACS), and subsequent Troponin only-MACS (T-MACS), rule risk stratify patients presenting with chest pain into 4 groups (Very low risk, low risk, moderate risk and high risk) with the aim of enabling immediate rule-in or rule-out of acute coronary syndromes in the ED. Low risk patients can be safely discharged from the ED with low probability of major adverse cardiac events (MACE) without further testing. We aimed to summarise the evidence for the use of the (T)MACS rules in the immediate rule-out of ACS in the ED in the very low risk category by undertaking a systematic review and meta-analysis. Methods We performed a keyword literature search of MEDLINE, EMBASE and Web of Science using MACS, T-MACS and acute coronary syndrome as search terms. After removal of duplicates, 2 authors reviewed the title and abstract to shortlist for full text review. Data was extracted independently by 2 authors, with disagreement resolved by discussion. Outcomes included were prevalent AMI and incident MACE. Quality assessment was performed using a QUADAS-2 model and meta-analysis was performed using STATA 15 running the METANDI and MIDAS commands. Results 9 studies were included (5 reporting T-MACS and 4 MACS). Data showing the summary AUC, combined sensitivity, and specificity for prevalent AMI and incident MACE in the very low risk (safe for immediate discharge) strata are shown in Table 1. Representative Forrest Plots for MACS and T-MACS are shown in figures 1 and 2 respectfully. Conclusion The MACS and T-MACS rules provide an accurate tool to identify a low risk chest pain population safe for immediate discharge from ED without the need for followup biomarker testing, with high sensitivity for AMI and ACS. Conflict of Interest None

Background Carcinoid heart disease (CHD) develops as a complication of neuroendocrine tumours (NET). The prognosis of CHD without intervention is poor; 3 year survival is estimated at 31%. Surgical valve replacement is the only treatment for CHD, but is associated with a high 30-day mortality (10-15%) and prolonged recovery. Aim To identify pre-operative transthoracic echocardiogram (PTTE) findings that could determine which patients have a high likelihood of post-surgical mortality at 1 year. Methods This retrospective observational cohort study recruited 88 patients with a confirmed diagnosis of CHD between 2005-19 at University Hospital Birmingham; 49 (56%) of these were treated surgically. Indications for surgery were: stable NET, symptomatic severe valvular dysfunction, progressive RV dilatation or RV dysfunction, absence of significant comorbidities. Surgery was not offered to those patients that were unlikely to benefit, either due to frailty or short life expectancy, or if the disease severity which did not warrant surgical intervention. Patient demographics are reported in Table 1. All patients underwent a standard PTTE. PTTE parameters assessed included: right ventricular (RV) size, RV function (qualitative), TAPSE, RV fractional area change, RV S wave velocity, left ventricular (LV) size, LV ejection fraction and valvular velocities. Surgery was performed by a single surgical team using bioprosthetic valve replacements. Across the patient population there were 48 tricuspid, 39 pulmonary, six aortic and four mitral replacements. Five patients also underwent a coronary bypass graft procedure; 12 had a patent foramen ovale closure and 23 required implantation of a permanent pacemaker. Results Patients were followed up for a median of 15 months (IQR: 6-59) after surgery, during which time there were 33 deaths, giving a median survival time of 30 months (IQR: 7-85). Increasingly severe RV dilatation was significantly associated with shorter survival (p=0.032). The estimated survival rate at three years was 67% in those with normal RV size, compared to 24% in the severe RV group (Figure 1). RV basal diameter was then further assessed. ROC curve analysis for the outcome of one year survival returned an area under the curve of 0.66 (SE=0.10). Youden’s index identified RV diameter >4.8cm to be the optimal cut-off for identifying high-risk patients. One year mortality rates were 26% (7/27) vs. 75% (9/12) in those with RV basal diameter of ≤4.8 vs. >4.8cm (p=0.006). Conclusion A pre-operative right ventricular basal diameter >4.8cm is associated with a near three-fold increase in post-operative mortality at one year. These findings highlight the importance of regular imaging in order to optimise the timing of surgery in patients with CHD. Conflict of Interest None

Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited pathology that can increase the risk of sudden death. Current task force criteria for echocardiographic diagnosis do not include new, regional assessment tools which may be relevant in a phenotypically diverse disease. We adopted a systematic review and meta-analysis approach to highlight echocardiographic indices that differentiated ARVC patients and healthy controls. Methods: Data was extracted and analysed from prospective trials that employed a case–control design meeting strict inclusion and exclusion as well as a priori quality criteria. Structural indices included proximal RV outflow tract (RVOT1) and RV diastolic area (RVDarea). Functional indices included RV fractional area change (RVFAC), tricuspid annular systolic excursion (TAPSE), peak systolic and early diastolic myocardial velocities (S′ and E′, respectively) and myocardial strain. Results: Patients with ARVC had larger RVOT1 (mean ± s.d.; 34 vs 28 mm, P < 0.001) and RVDarea (23 vs 18 cm2, P < 0.001) compared with healthy controls. ARVC patients also had lower RVFAC (38 vs 46%, P < 0.001), TAPSE (17 vs 23 mm, P < 0.001), S′ (9 vs 12 cm/s, P < 0.001), E′ (9 vs 13 cm/s, P < 0.001) and myocardial strain (−17 vs −30%, P < 0.001). Conclusion: The data from this meta-analysis support current task force criteria for the diagnosis of ARVC. In addition, other RV measures that reflect the complex geometry and function in ARVC clearly differentiated between ARVC and healthy controls and may provide additional diagnostic and management value. We recommend that future working groups consider this data when proposing new/revised criteria for the echocardiographic diagnosis of ARVC.

Train axle inspection tasks rely on human operators working in and around depots and pits, searching for and identifying defects, with the use of non-destructive testing methods. Characteristics of the working environment and equipment design increase the likelihood of human error due to a variety of issues such as poor lighting, restricted access, awkward postures and limitations associated with the design of equipment interfaces. The purpose of this discussion paper is to encourage debate amongst the rail industry by proposing a new concept for carrying out this task, namely human-robot collaboration. Literature review from comparable domains has identified that human-collaborative robotic systems have been proposed and developed to optimise asset health monitoring. This concept could potentially be applied to train axle inspection with profound implications. At the same time, it is acknowledged that integrating humans and robotic systems within the same workspace will be a significant challenge and will require a holistic human factors approach. To this end, the latest empirical research on the key human factors that need to be considered, at an organisational and individual level, for the successful integration of humans and robots in industrial applications is presented.

For many patients with end-stage heart failure, heart transplantation is the only remaining option to prolong survival and provide symptom relief. Transthoracic echo is the modality of choice in assessing a patient for potential left ventricular assist device (LVAD) insertion. There are currently no guidelines available, and assessing this specific patient population can prove extremely challenging. As such, an understanding of LVAD mechanism, the important physiological consequences of device implantation together with the related echocardiographic examination is vital to accurately and effectively gauge correct patient selection and also improve implantation success. This review aims to highlight the common devices implanted, how these devices affect cardiac physiology and hemodynamics, and therefore discuss the major echocardiographic variables that should be assessed predevice implantation. (Echocardiography 2012;29:52-58).

Sudden death of competitive athletes is rare. However, they continue to have an impact on both the lay and medical communities. These deaths challenge the perception that trained athletes represent the healthiest segment of modern society. There is an increasing frequency of such reported deaths worldwide and the visibility of this issue is underlined by the high-profile nature of each case. Differential diagnosis between pathological and the physiologic (nonpathological) responses to high levels of physical training has become clinically more important. The purpose of this review is to highlight the main echocardiograph characteristics related to different types of training/sports participation and to highlight already recognized and newer concepts in their clinical assessment.

Medalists are a unique subset of patients with more than 50 years of type 1 diabetes. One would expect these patients to have significant microvascular and macrovascular complications. However, the Joslin observational study showed that of their medalists, a substantial proportion remained free of proliferative diabetic retinopathy (42.6%), nephropathy (86.9%), and neuropathy (39.4%) (1). Whether this protection extends to the heart is unknown. We therefore comprehensively investigated cardiac structure and function in 14 medalists and 9 control subjects. They underwent rest and stress (vasodilator) perfusion MRI to exclude significant coronary artery disease and echocardiography to quantify cardiac structure and left ventricular systolic function, including strain, strain rate, torsion, and diastolic dimensions. Pulsed-wave Doppler sequences of the mitral valve assessing passive early (E) and active atrial (A) …

This study investigated the effects of a pragmatic lifestyle intervention in obese adults with continuous positive airway pressure-treated obstructive sleep apnoea hypopnoea syndrome (OSAHS). Sixty patients were randomised 1 : 1 to either a 12-week lifestyle intervention or an advice-only control group. The intervention involved supervised exercise sessions, dietary advice, and the promotion of lifestyle behaviour change using cognitive-behavioural techniques. Outcomes were assessed at baseline (week 0), intervention end-point (week 13), and follow-up (week 26). The primary outcome was 13-week change in body mass. Secondary outcomes included anthropometry, blood-borne biomarkers, exercise capacity, and health-related quality of life. At end-point, the intervention group exhibited small reductions in body mass (−1.8 [−3.0, −0.5] kg;P=0.007) and body fat percentage (−1 [−2, 0]%;P=0.044) and moderate improvements in C-reactive protein (−1.3 [−2.4, −0.2] mg·L−1;P=0.028) and exercise capacity (95 [50, 139] m;P<0.001). At follow-up, changes in body mass (−2.0 [−3.5, −0.5] kg;P=0.010), body fat percentage (−1 [−2, 0]%;P=0.033), and C-reactive protein (−1.3 [−2.5, −0.1] mg·L−1;P=0.037) were maintained and exercise capacity was further improved (132 [90, 175] m;P<0.001). This trial is registered with ClinicalTrials.govNCT01546792.

This study assessed the feasibility of a 12-week program of exercise, with and without intramuscular testosterone supplementation, in male patients with chronic heart failure (CHF) and low testosterone status and collected preliminary data for key health outcomes.Male patients with CHF (n = 41, age 67.2 years, range 51-84 years) with mean ± SD testosterone levels of 10.7 ± 2.6 nmol/L (309 ± 76 ng/dL) were randomly allocated to exercise with testosterone or placebo groups. Feasibility was assessed in terms of recruitment, intervention compliance, and attrition. Outcomes included an incremental shuttle walk test, peak oxygen uptake, muscular strength, echocardiographic measures, N-terminal pro-brain natriuretic peptide, inflammatory markers, depression (Beck Depression Inventory), and health-related quality of life (Minnesota Living with Heart Failure Questionnaire and Medical Outcomes Study Short-Form).Attrition was 30% but with 100% compliance to exercise and injections in patients who completed the study. Similar improvements in shuttle walk test (18% vs 19%), body mass (-1.3 kg vs -1.0 kg), and hand grip strength (2.1 kg vs 2.5 kg) from baseline were observed in both groups. The exercise with testosterone group showed improvements from baseline in peak oxygen uptake (P.01), Beck Depression Inventory (P.05), leg strength (P.05), and several Medical Outcomes Study Short-Form quality of life domains (P.05), which were generally not apparent in the exercise with placebo group. Echocardiographic measures, N-terminal pro-brain natriuretic peptide, and inflammatory markers were mostly unchanged.This study shows for the first time that testosterone supplementation during a program of exercise rehabilitation is feasible and can positively impact on a range of key health outcomes in elderly male patients with CHF who have a low testosterone status.

AIMS: To compare left ventricular (LV) volume indices and the ejection fraction (EF) obtained using real-time three-dimensional echocardiography (RT3DE) and cardiovascular magnetic resonance (CMR) in unselected patients representative of 'real-world' clinical practice, and to determine the effect of RT3DE image quality on these parameters. METHODS AND RESULTS: Sixty consecutive patients undergoing CMR underwent same day RT3DE. LV volume and EF measurements were made using both modalities and compared. All scans were independently analysed by a second observer to assess inter-observer variability, and 40% were re-analysed to assess intra-observer variability. RT3DE image quality was graded as good, adequate, and non-analysable. Thirteen (22%) patients had good RT3DE image quality, 29 (48%) had adequate image quality, and 18 (30%) had image quality precluding analysis. Body mass index and arrhythmia frequency were higher in patients with suboptimal image quality. RT3DE significantly underestimated end-diastolic volume (EDV) (-45 � 35 mL, P < 0.001), end-systolic volume (ESV) (-11 � 24 mL, P = 0.004), and EF (-7 � 9%, P < 0.001) compared with CMR although the degree of underestimation was substantially less when image quality was good. Eleven patients (18%) classified as having a normal EF by CMR had a reduced EF according to RT3DE, all but one of which had suboptimal image quality. Observer variability for RT3DE was higher than for CMR for all parameters, however, the difference was not significant when RT3DE image quality was good. CONCLUSIONS: In contrast to previously published data from highly selected patient groups, 'real-world' RT3DE substantially underestimates LV volumes and EF. The degree of underestimation is related to image quality.

Cardiovascular disease is one of the leading causes of death in industrialized nations worldwide. Traditional assessment of cardiovascular disease often involves invasive procedures (e.g., coronary angiography) and also provides little functional information of arterial reactivity. The emergence of the assessment of "subclinical" atherosclerosis and the role of arterial stiffness in both cardiovascular prognosis and cardiovascular risk have become more widely accepted and used in modern clinical practice and research. Flow-mediated dilatation can be used to directly assess endothelial function in healthy and diseased populations. This review aims to provide the reader with an insight into the technique and clinical applications of this recently new tool for the assessment of cardiovascular disease and risk.

Sudden death of competitive athletes is rare. These deaths challenge the perception that trained athletes represent the healthiest segment of modern society. The increasing frequency of such reported deaths worldwide and the visibility of the issue is underlined by the high-profile nature of each case. The majority of these deaths have been due to a variety of undiagnosed cardiovascular diseases. Marfan syndrome is a heritable disorder of the connective tissue that can hold life threatening consequences, especially for the athletic population. This paper will aim to review cardiovascular pathophysiology and assessment in relation to Marfan syndrome with particular reference to echocardiography and the athletic population.

The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor (EGF) receptor (HER) 2-positive targeted treatment (e.g. trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.

The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor receptor (HER) 2-positive targeted treatment (e.g., trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented., Central Illustration, Highlights • Cardio-oncology patients account for an increasing proportion of echocardiography requests. • Accurate assessment of LV systolic function is critical to decision-making in this patient group. • 2D LVEF, 3D LVEF, GLS, and RV assessment should be used in the echocardiographic assessment of these patients. • The clinical implications of a significant decline in GLS with potentially cardiotoxic cancer therapy require further investigation.

The aim of the study is to establish the impact of 2D echocardiographic methods on absolute values for aortic root dimensions and to describe any allometric relationship to body size. We adopted a nationwide cross-sectional prospective multicentre design using images obtained from studies utilising control groups or where specific normality was being assessed. A total of 248 participants were enrolled with no history of cardiovascular disease, diabetes, hypertension or abnormal findings on echocardiography. Aortic root dimensions were measured at the annulus, the sinus of Valsalva, the sinotubular junction, the proximal ascending aorta and the aortic arch using the inner edge and leading edge methods in both diastole and systole by 2D echocardiography. All dimensions were scaled allometrically to body surface area (BSA), height and pulmonary artery diameter. For all parameters with the exception of the aortic annulus, dimensions were significantly larger in systole (PPb exponent of BSA0.6 in order to achieve size independence. Similarly, ratio scaling to height in subjects under the age of 40 years also produced size independence. In conclusion, the largest aortic dimensions occur in systole while using the leading edge method. Reproducibility of measurement, however, is better when assessing aortic dimensions in diastole. There is an allometric relationship to BSA and, therefore, allometric scaling in the order of BSA0.6 provides a size-independent index that is not influenced by the age or gender.

Sudden cardiac death (SCD) in an athlete is a rare but tragic event. In view of this, pre-participation cardiac screening is mandatory across many sporting disciplines to identify those athletes at risk. Echocardiography is a primary investigation utilized in the pre-participation setting and in 2013 the British Society of Echocardiography and Cardiac Risk in the Young produced a joint policy document providing guidance on the role of echocardiography in this setting. Recent developments in our understanding of the athlete’s heart and the application of echocardiography have prompted this 2018 update.