Skip to main content
PMC home page
British Journal of Sports Medicine logoLink to British Journal of Sports Medicine
. 1996 Mar;30(1):5–10. doi: 10.1136/bjsm.30.1.5

The athlete's heart: is big beautiful?

R J Shephard 1
PMCID: PMC1332256  PMID: 8665119

Abstract

Development of the concept of "athlete's heart" is traced through early clinical and radiographic studies to modern echocardiography and magnetic resonance imaging. It is noted that the lower limits of criteria for the diagnosis of a "pathological" enlargement of the heart have frequently been revised in an upward direction, as the prevalence of large hearts has been recognised in both endurance and power sports competitors who are in good health. Belief that hypertrophic cardiomyopathy is the commonest cause of sports related death in young adults is traced to weak diagnostic criteria and frequent republication of a very small group of cases. Although the existence of a congenital myocardial dystrophy is now well established, this condition is extremely rare, and has no particular predilection for athletes. Genetically based screening tests may become available in the future, but the exclusion of young adults from sports participation on echocardiographic criteria appears costly and ineffective. For most people, the development of a large heart is not a pathological sign--rather, it is a desirable outcome that will enhance performance on the sports field, and will allow longer independence in old age.

Full text

PDF
10

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Allen H. D., Goldberg S. J., Sahn D. J., Schy N., Wojcik R. A quantitative echocardiographic study of champion childhood swimmers. Circulation. 1977 Jan;55(1):142–145. doi: 10.1161/01.cir.55.1.142. [DOI] [PubMed] [Google Scholar]
  2. Brandenburg R. O. Syncope and sudden death in hypertrophic cardiomyopathy. J Am Coll Cardiol. 1990 Apr;15(5):962–964. doi: 10.1016/0735-1097(90)90224-d. [DOI] [PubMed] [Google Scholar]
  3. Colan S. D., Sanders S. P., Borow K. M. Physiologic hypertrophy: effects on left ventricular systolic mechanics in athletes. J Am Coll Cardiol. 1987 Apr;9(4):776–783. doi: 10.1016/s0735-1097(87)80232-2. [DOI] [PubMed] [Google Scholar]
  4. Dickhuth H. H., Nause A., Staiger J., Bonzel T., Keul J. Two-dimensional echocardiographic measurements of left ventricular volume and stroke volume of endurance-trained athletes and untrained subjects. Int J Sports Med. 1983 Feb;4(1):21–26. doi: 10.1055/s-2008-1026011. [DOI] [PubMed] [Google Scholar]
  5. Dickhuth H. H., Röcker K., Hipp A., Heitkamp H. C., Keul J. Echocardiographic findings in endurance athletes with hypertrophic non-obstructive cardiomyopathy (HNCM) compared to non-athletes with HNCM and to physiological hypertrophy (athlete's heart). Int J Sports Med. 1994 Jul;15(5):273–277. doi: 10.1055/s-2007-1021059. [DOI] [PubMed] [Google Scholar]
  6. Ehsani A. A., Hagberg J. M., Hickson R. C. Rapid changes in left ventricular dimensions and mass in response to physical conditioning and deconditioning. Am J Cardiol. 1978 Jul;42(1):52–56. doi: 10.1016/0002-9149(78)90984-0. [DOI] [PubMed] [Google Scholar]
  7. Fleck S. J., Henke C., Wilson W. Cardiac MRI of elite junior Olympic weight lifters. Int J Sports Med. 1989 Oct;10(5):329–333. doi: 10.1055/s-2007-1024923. [DOI] [PubMed] [Google Scholar]
  8. George K. P., Wolfe L. A., Burggraf G. W. The 'athletic heart syndrome'. A critical review. Sports Med. 1991 May;11(5):300–330. doi: 10.2165/00007256-199111050-00003. [DOI] [PubMed] [Google Scholar]
  9. Gott P. H., Roselle H. A., Crampton R. S. The athletic heart syndrome. Five-year cardiac evaluation of a champion athlete. Arch Intern Med. 1968 Oct;122(4):340–344. doi: 10.1001/archinte.122.4.340. [DOI] [PubMed] [Google Scholar]
  10. Hillis W. S., McIntyre P. D., Maclean J., Goodwin J. F., McKenna W. J. ABC of sports medicine. Sudden death in sport. BMJ. 1994 Sep 10;309(6955):657–660. doi: 10.1136/bmj.309.6955.657. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Huston T. P., Puffer J. C., Rodney W. M. The athletic heart syndrome. N Engl J Med. 1985 Jul 4;313(1):24–32. doi: 10.1056/NEJM198507043130106. [DOI] [PubMed] [Google Scholar]
  12. Ikäheimo M. J., Palatsi I. J., Takkunen J. T. Noninvasive evaluation of the athletic heart: sprinters versus endurance runners. Am J Cardiol. 1979 Jul;44(1):24–30. doi: 10.1016/0002-9149(79)90246-7. [DOI] [PubMed] [Google Scholar]
  13. Keys A., Friedell H. L. SIZE AND STROKE OF THE HEART IN YOUNG MEN IN RELATION TO ATHLETIC ACTIVITY. Science. 1938 Nov 11;88(2289):456–458. doi: 10.1126/science.88.2289.456. [DOI] [PubMed] [Google Scholar]
  14. Kohl H. W., 3rd, Powell K. E. What is exertion-related sudden cardiac death? Sports Med. 1994 Apr;17(4):209–212. doi: 10.2165/00007256-199417040-00001. [DOI] [PubMed] [Google Scholar]
  15. Longhurst J. C., Kelly A. R., Gonyea W. J., Mitchell J. H. Echocardiographic left ventricular masses in distance runners and weight lifters. J Appl Physiol Respir Environ Exerc Physiol. 1980 Jan;48(1):154–162. doi: 10.1152/jappl.1980.48.1.154. [DOI] [PubMed] [Google Scholar]
  16. Marian A. J., Kelly D., Mares A., Jr, Fitzgibbons J., Caira T., Qun-Tao, Hill R., Perryman M. B., Roberts R. A missense mutation in the beta myosin heavy chain gene is a predictor of premature sudden death in patients with hypertrophic cardiomyopathy. J Sports Med Phys Fitness. 1994 Mar;34(1):1–10. [PubMed] [Google Scholar]
  17. Maron B. J., Gottdiener J. S., Bonow R. O., Epstein S. E. Hypertrophic cardiomyopathy with unusual locations of left ventricular hypertrophy undetectable by M-mode echocardiography. Identification by wide-angle two-dimensional echocardiography. Circulation. 1981 Feb;63(2):409–418. doi: 10.1161/01.cir.63.2.409. [DOI] [PubMed] [Google Scholar]
  18. Maron B. J., Isner J. M., McKenna W. J. 26th Bethesda conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. Task Force 3: hypertrophic cardiomyopathy, myocarditis and other myopericardial diseases and mitral valve prolapse. Med Sci Sports Exerc. 1994 Oct;26(10 Suppl):S261–S267. [PubMed] [Google Scholar]
  19. McKenna W. J., Camm A. J. Sudden death in hypertrophic cardiomyopathy. Assessment of patients at high risk. Circulation. 1989 Nov;80(5):1489–1492. doi: 10.1161/01.cir.80.5.1489. [DOI] [PubMed] [Google Scholar]
  20. Menapace F. J., Hammer W. J., Ritzer T. F., Kessler K. M., Warner H. F., Spann J. F., Bove A. A. Left ventricular size in competitive weight lifters: an echocardiographic study. Med Sci Sports Exerc. 1982;14(1):72–75. doi: 10.1249/00005768-198201000-00014. [DOI] [PubMed] [Google Scholar]
  21. Milliken M. C., Stray-Gundersen J., Peshock R. M., Katz J., Mitchell J. H. Left ventricular mass as determined by magnetic resonance imaging in male endurance athletes. Am J Cardiol. 1988 Aug 1;62(4):301–305. doi: 10.1016/0002-9149(88)90228-7. [DOI] [PubMed] [Google Scholar]
  22. Mitten M. J., Maron B. J. Legal considerations that affect medical eligibility for competitive athletes with cardiovascular abnormalities and acceptance of Bethesda Conference recommendations. Med Sci Sports Exerc. 1994 Oct;26(10 Suppl):S238–S241. [PubMed] [Google Scholar]
  23. Morganroth J., Maron B. J., Henry W. L., Epstein S. E. Comparative left ventricular dimensions in trained athletes. Ann Intern Med. 1975 Apr;82(4):521–524. doi: 10.7326/0003-4819-82-4-521. [DOI] [PubMed] [Google Scholar]
  24. Nienaber C. A., Hiller S., Spielmann R. P., Geiger M., Kuck K. H. Syncope in hypertrophic cardiomyopathy: multivariate analysis of prognostic determinants. J Am Coll Cardiol. 1990 Apr;15(5):948–955. doi: 10.1016/0735-1097(90)90222-b. [DOI] [PubMed] [Google Scholar]
  25. Oakley D. G., Oakley C. M. Significance of abnormal electrocardiograms in highly trained athletes. Am J Cardiol. 1982 Nov;50(5):985–989. doi: 10.1016/0002-9149(82)90406-4. [DOI] [PubMed] [Google Scholar]
  26. Park R. C., Crawford M. H. Heart of the athlete. Curr Probl Cardiol. 1985 May;10(5):1–73. doi: 10.1016/0146-2806(85)90010-6. [DOI] [PubMed] [Google Scholar]
  27. Parker B. M., Londeree B. R., Cupp G. V., Dubiel J. P. The noninvasive cardiac evaluation of long-distance runners. Chest. 1978 Mar;73(3):376–381. doi: 10.1378/chest.73.3.376. [DOI] [PubMed] [Google Scholar]
  28. Pearson A. C., Schiff M., Mrosek D., Labovitz A. J., Williams G. A. Left ventricular diastolic function in weight lifters. Am J Cardiol. 1986 Dec 1;58(13):1254–1259. doi: 10.1016/0002-9149(86)90392-9. [DOI] [PubMed] [Google Scholar]
  29. Pekkanen J., Marti B., Nissinen A., Tuomilehto J., Punsar S., Karvonen M. J. Reduction of premature mortality by high physical activity: a 20-year follow-up of middle-aged Finnish men. Lancet. 1987 Jun 27;1(8548):1473–1477. doi: 10.1016/s0140-6736(87)92218-5. [DOI] [PubMed] [Google Scholar]
  30. Perrault H., Turcotte R. A. Exercise-induced cardiac hypertrophy. Fact or fallacy? Sports Med. 1994 May;17(5):288–308. doi: 10.2165/00007256-199417050-00003. [DOI] [PubMed] [Google Scholar]
  31. Raskoff W. J., Goldman S., Cohn K. The "athletic heart". Prevalence and physiological significance of left ventricular enlargement in distance runners. JAMA. 1976 Jul 12;236(2):158–162. doi: 10.1001/jama.236.2.158. [DOI] [PubMed] [Google Scholar]
  32. Reichek N., Devereux R. B. Left ventricular hypertrophy: relationship of anatomic, echocardiographic and electrocardiographic findings. Circulation. 1981 Jun;63(6):1391–1398. doi: 10.1161/01.cir.63.6.1391. [DOI] [PubMed] [Google Scholar]
  33. Rodriguez Reguero J. J., Iglesias Cubero G., Lòpez de la Iglesia J., Terrados N., Gonzalez V., Cortina R., Cortina A. Prevalence and upper limit of cardiac hypertrophy in professional cyclists. Eur J Appl Physiol Occup Physiol. 1995;70(5):375–378. doi: 10.1007/BF00618486. [DOI] [PubMed] [Google Scholar]
  34. Roeske W. R., O'Rourke R. A., Klein A., Leopold G., Karliner J. S. Noninvasive evaluation of ventricular hypertrophy in professional athletes. Circulation. 1976 Feb;53(2):286–291. doi: 10.1161/01.cir.53.2.286. [DOI] [PubMed] [Google Scholar]
  35. Romhilt D. W., Estes E. H., Jr A point-score system for the ECG diagnosis of left ventricular hypertrophy. Am Heart J. 1968 Jun;75(6):752–758. doi: 10.1016/0002-8703(68)90035-5. [DOI] [PubMed] [Google Scholar]
  36. Rosenzweig A., Watkins H., Hwang D. S., Miri M., McKenna W., Traill T. A., Seidman J. G., Seidman C. E. Preclinical diagnosis of familial hypertrophic cardiomyopathy by genetic analysis of blood lymphocytes. N Engl J Med. 1991 Dec 19;325(25):1753–1760. doi: 10.1056/NEJM199112193252501. [DOI] [PubMed] [Google Scholar]
  37. Sadaniantz A., Thompson P. D. The problem of sudden death in athletes as illustrated by case studies. Sports Med. 1990 Apr;9(4):199–204. doi: 10.2165/00007256-199009040-00001. [DOI] [PubMed] [Google Scholar]
  38. Sarna S., Sahi T., Koskenvuo M., Kaprio J. Increased life expectancy of world class male athletes. Med Sci Sports Exerc. 1993 Feb;25(2):237–244. [PubMed] [Google Scholar]
  39. Scott R. C. Ventricular hypertrophy. Cardiovasc Clin. 1973;5(3):219–253. [PubMed] [Google Scholar]
  40. Shapiro L. M. Left ventricular hypertrophy in athletes in relation to the type of sport. Sports Med. 1987 Jul-Aug;4(4):239–244. doi: 10.2165/00007256-198704040-00002. [DOI] [PubMed] [Google Scholar]
  41. Shapiro L. M. Physiological left ventricular hypertrophy. Br Heart J. 1984 Aug;52(2):130–135. doi: 10.1136/hrt.52.2.130. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Smith D. M. Pre-participation physical evaluations. Development of uniform guidelines. Sports Med. 1994 Nov;18(5):293–300. doi: 10.2165/00007256-199418050-00001. [DOI] [PubMed] [Google Scholar]
  43. Snoeckx L. H., Abeling H. F., Lambregts J. A., Schmitz J. J., Verstappen F. T., Reneman R. S. Echocardiographic dimensions in athletes in relation to their training programs. Med Sci Sports Exerc. 1982;14(6):428–434. doi: 10.1249/00005768-198206000-00004. [DOI] [PubMed] [Google Scholar]
  44. Solomon S. D., Jarcho J. A., McKenna W., Geisterfer-Lowrance A., Germain R., Salerni R., Seidman J. G., Seidman C. E. Familial hypertrophic cardiomyopathy is a genetically heterogeneous disease. J Clin Invest. 1990 Sep;86(3):993–999. doi: 10.1172/JCI114802. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Spirito P., Chiarella F., Carratino L., Berisso M. Z., Bellotti P., Vecchio C. Clinical course and prognosis of hypertrophic cardiomyopathy in an outpatient population. N Engl J Med. 1989 Mar 23;320(12):749–755. doi: 10.1056/NEJM198903233201201. [DOI] [PubMed] [Google Scholar]
  46. Spirito P., Pelliccia A., Proschan M. A., Granata M., Spataro A., Bellone P., Caselli G., Biffi A., Vecchio C., Maron B. J. Morphology of the "athlete's heart" assessed by echocardiography in 947 elite athletes representing 27 sports. Am J Cardiol. 1994 Oct 15;74(8):802–806. doi: 10.1016/0002-9149(94)90439-1. [DOI] [PubMed] [Google Scholar]
  47. Thierfelder L., Watkins H., MacRae C., Lamas R., McKenna W., Vosberg H. P., Seidman J. G., Seidman C. E. Alpha-tropomyosin and cardiac troponin T mutations cause familial hypertrophic cardiomyopathy: a disease of the sarcomere. Cell. 1994 Jun 3;77(5):701–712. doi: 10.1016/0092-8674(94)90054-x. [DOI] [PubMed] [Google Scholar]
  48. Urhausen A., Kindermann W. Echocardiographic findings in strength- and endurance-trained athletes. Sports Med. 1992 Apr;13(4):270–284. doi: 10.2165/00007256-199213040-00004. [DOI] [PubMed] [Google Scholar]
  49. Van Camp S. P., Bloor C. M., Mueller F. O., Cantu R. C., Olson H. G. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc. 1995 May;27(5):641–647. [PubMed] [Google Scholar]
  50. Weidenbener E. J., Krauss M. D., Waller B. F., Taliercio C. P. Incorporation of screening echocardiography in the preparticipation exam. Clin J Sport Med. 1995;5(2):86–89. doi: 10.1097/00042752-199504000-00003. [DOI] [PubMed] [Google Scholar]
  51. Wigle E. D., Sasson Z., Henderson M. A., Ruddy T. D., Fulop J., Rakowski H., Williams W. G. Hypertrophic cardiomyopathy. The importance of the site and the extent of hypertrophy. A review. Prog Cardiovasc Dis. 1985 Jul-Aug;28(1):1–83. doi: 10.1016/0033-0620(85)90024-6. [DOI] [PubMed] [Google Scholar]
  52. Williams C. C., Bernhardt D. T. Syncope in athletes. Sports Med. 1995 Mar;19(3):223–234. doi: 10.2165/00007256-199519030-00006. [DOI] [PubMed] [Google Scholar]
  53. Winget J. F., Capeless M. A., Ades P. A. Sudden death in athletes. Sports Med. 1994 Dec;18(6):375–383. doi: 10.2165/00007256-199418060-00003. [DOI] [PubMed] [Google Scholar]

Articles from British Journal of Sports Medicine are provided here courtesy of BMJ Publishing Group

RESOURCES