Although numerous structural changes occur in athletic heart syndrome, such as hypertrophy of the heart (but mainly of the left ventricle), significant rise in the maximal oxygen uptake, increased stroke volume, and thickening of the myocardium, this phenomenon is considered to be a physiological response that meets the demands of the body to perform the necessary movements and actions [1] [2] [3] [4]. This syndrome is most commonly encountered among athletes who participate in sports that require endurance - triathlon, long-to-middle distance running, speed skating, and cross-country skiing [1]. Because of the heart's increased size, diameter, and the strength with which it expulses blood, one of the most common signs of athletic heart syndrome is sinus bradycardia [1]. Heart rate can be as low as 30 beats per minute on Holter monitoring, or it can go even less than 30 beats during sleep [1]. Sinus arrhythmias are the second important component of the clinical presentation of athletic heart syndrome [1]. First or second degree atrioventricular (AV) blocks, incomplete right bundle branch block (RBBB), extrasystoles, and early repolarization (presenting as ST elevation) are frequent exercise-related findings that are interpreted as physiological [1] [4]. Atrial fibrillation is noticed in aged athletes who were involved in endurance training [1] [4].

• Coarctation of the Aorta

  […] of the aorta; recognition of the physical stigmata of Marfan's syndrome and brachial blood pressure measurement in the seated position ( Table 3 ). [aafp.org]

  […] of the aorta; (3) recognition of the physical stigmata of Marfan syndrome; and (4) brachial blood pressure measurement in the sitting position. [doi.org]

• Heart Disease

  Information as to whether the electrical remodelling of the athlete's heart mimics that of patients with heart disease, and therefore serves as a substrate for ventricular dysrhythmias, is conflicting. [ncbi.nlm.nih.gov]

  Treatments include: We treat a full range of hereditary heart and blood vessel diseases: Clinical trials for inherited heart disease often test new medications. [familyheart.stanford.edu]

  However, by 1977, the medical journals were already reporting that running did not create an immunity to heart disease, including a study published by Dr. Timothy Noakes entitled, Coronary Heart Disease in Marathon Runners. [philmaffetone.com]

  Disease 502 The Heart and Pregnancy 537 Chapter32 Women and Heart Disease 553 The Elderly and Aging 561 Chapter34 EndofLife Care 587 The Heart and Other Organ Systems 595 Chapter 35B Hematologic Disorders and the Heart 604 Chapter35C The Heart and the [books.google.com]

  | September 6, 2014 | Heart Disease FAQ | Athletic heart syndrome Heart Disease FAQ It is common knowledge that your muscles become stronger and thicker if you exercise them frequently. The same is true of the heart muscle. [cardiophile.org]

• Tachycardia

  […] a study of normotensive athletes with cardiac hypertrophy, impairment of cardiopulmonary receptor reflexes was found (Giannattasio et al 1990).This indicates a potential lack of appropriate response to haemorrhage or orthostatic stress by means of a tachycardia [rrnursingschool.biz]

  This will then decrease the blood pressure, and hence produce a reflex tachycardia as explained above. KETAMINE causes stimulation of the sympathetic nervous system, and therefore produces a tachycardia. [afpafitness.com]

  System 613 Chapter35D Cardiac Manifestations of Selected Neurologic 626 Chapter35E Cardiovascular Manifestations of Rheumatic 638 Chapter35F The Heart and Infectious Diseases 656 Chapter36 Substance Abuse and the Heart 669 Chapter 63 961 Ventricular Tachycardia [books.google.com]

  Bottom, Ambulatory Holter ECG recording from 24-year-old male basketball player with frequent palpitations showing asymptomatic 10-beat burst of nonsustained ventricular tachycardia. [doi.org]

• Cardiomegaly

  People diagnosed with athlete’s heart commonly display three signs that would usually indicate a heart condition when seen in a regular person: bradycardia, cardiomegaly, and cardiac hypertrophy. [definitions.net]

  Athlete's heart is not dangerous for athletes (though if a nonathlete has symptoms of bradycardia, cardiomegaly, and cardiac hypertrophy, another illness may be present). [en.wikipedia.org]

  Those with AHS also have an enlarged heart (cardiomegaly) and thickening of the muscular wall of the heart (cardiac hypertrophy). [diseaseinfosearch.org]

  Clinical relevance Athlete's heart is not dangerous for athletes (though if a nonathlete has symptoms of bradycardia, cardiomegaly, and cardiac hypertrophy, another illness may be present). [ipfs.io]

  There was no history of cardiac disease, dyspnea, orthopnea, edema, rheumatic fever, chorea, syphilis, inadequate diet, anemia, hypertension, or familial cardiomegaly. [longislandsportsmassage.com]

• Systolic Murmur

  The changes are asymptomatic; signs include bradycardia, a systolic murmur, and extra heart sounds. ECG abnormalities are common. Diagnosis is clinical or by echocardiography. No treatment is necessary. [merckmanuals.com]

  Physiological splitting of the second heart sound and a systolic ejection murmur which varied with postural changes were audible. No diastolic murmur or gallop were present. [longislandsportsmassage.com]

  Signs include sinus bradycardia (a resting heart rate of fewer than 60 beats per minute), a systolic murmur, and extra heart sounds. ECG abnormalities are common. No treatment is necessary but it must be distinguished from serious cardiac disorders. [iswimbikerun.wordpress.com]

  Resting sinus bradycardia, third and fourth heart sounds, systolic murmurs, a variety of ECG abnormalities, and cardiac enlargement on chest x-ray are characteristic. [afpafitness.com]

• Slow Pulse

  The two most common findings in trained athletes are bradycardia, or a slow pulse (less than 70 beats per minute), and phasic sinus arrhythmia, a pulse that speeds and slows with respiration. [sportsdoctor.com]

  The athletic heart may simulate the diseased heart by exhibiting a systolic murmur, a slow pulse rate, a variety of arrhythmias and disturbances of cardiac conduction, elevation of the S-T segments, and cardiac enlargement by x-ray. [longislandsportsmassage.com]

Many studies stress the need for discriminating athletic heart syndrome from pathological conditions that may present in a similar fashion and pose a life-threatening risk -hypertrophic cardiomyopathy, pathologically enlarged left ventricle, Wolff-Parkinson-White syndrome, Brugada syndrome, arrhythmogenic right ventricular dysplasia, and QT syndrome should be included in the differential diagnosis [1] [2] [3] [4] [5]. The physician should obtain a detailed history during which the patient must be asked about the sport he/she is practicing, for how many years, and on what level (amateur or professional). A thorough physical examination should follow, with an emphasis on cardiac auscultation that will almost universally reveal bradycardia at rest. Electrocardiography (ECG) and Holter monitoring are very useful diagnostic modalities that evaluate the cardiac conduction system and determine if any abnormalities are present [1] [4] [6]. As mentioned previously, sinus bradycardia, AV blocks, extrasystoles, and early repolarization are hallmarks of athletic heart syndrome [1] [4]. If, however, ECG reveals left anterior or posterior hemiblocks, complete bundle branch blocks, ventricular preexcitation (an indicator of Wolff-Parkinson-White syndrome), abnormal Q waves, ST depression, or epsilon waves, further evaluation is mandatory [1] [4]. Cardiac ultrasonography is crucial for examining the morphology of the heart and its characteristics and should be used to confirm that the dimensions of heart are within the criteria for athletic heart syndrome [1] [2] [7]. The end-diastolic diameter of the left ventricle should not exceed 63 mm in men and 60 mm in women, Myocardial thickness of the left ventricle should not exceed 13 and 12 mm respectively, and the heart mass should not be over 7.5 g/kg for men and 7 g/kg in women [1] [8].

• Left Ventricular Hypertrophy

  Ventricular Hypertrophy criteria Right Ventricular Hypertrophy criteria Wide QRS Complex (incomplete Right Bundle Branch Block ) Athletes: 14% Incidence Gene ral athletes: 10% Incidence Repolarization changes ST segment elevation Flipped T Wave s Increased [fpnotebook.com]

  The patient shows left ventricular hypertrophy, and the absence of a Q wave in leads I and V 6 suggests the presence of left ventricular conduction delay. [rjmatthewsmd.com]

  None May be present BP response to exercise Normal Normal or reduced systolic BP response Deconditioning Left ventricular hypertrophy regression No left ventricular hypertrophy regression The medical history of the patient (endurance sports) and physical [ipfs.io]

  HCM is characterized by disparity between the magnitude of LVH and the left ventricular cavity size; LVH occurs at the expense of left ventricular cavity size. [acc.org]

  Assessment of left ventricular hypertrophy in a trained athlete: differential diagnosis of physiologic athlete’s heart from pathologic hypertrophy. Prog Cardiovasc Dis. 2012 Mar-Apr;54(5):387-96. [completehumanperformance.com]

• Abnormal ECG

  He gets an ECG before the operation to screen for any unrecognized heart problems….and behold, he has an abnormal ECG. [athletesheart.org]

  Although those with abnormal ECG presented larger cardiac dimensions as compared to those with normal ECG, none of them had abnormal values of wall thickness or diastolic volumes in the echocardiography [16]. [escardio.org]

  ECGs that were distinctly abnormal (black bars), mildly abnormal (gray bars), and normal or with minor alterations (white bars) are depicted as proportions of all the athletes participating in each sporting discipline. X-C indicates cross-country. [doi.org]

• Electrocardiogram Change

  Diagnostics: Electrocardiogram Electrocardiogram changes resolve when exercising Sinus Bradycardia with or without arrhythmia Atrioventricular conduction delays First degree block Athletes: 10-33% Incidence Gene ral population: 0.65% Incidence Mobitz [fpnotebook.com]

[…] strategies of RED-S Treatment strategies for low EA The treatment of low EA should involve an increase in EI, reduction in exercise or a combination of both. [doi.org]

Managing treatment for Heart Disease is a highly personalized process. [familyheart.stanford.edu]

Treatment Treatment is not required for individuals diagnosed with athlete’s heart. No evidence has been found of any long-term danger from the changes regular exercise may cause to the heart. [sportsmedtoday.com]

الصفحة 24 - Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). ‏ الصفحة 134 - Sacks FM, Pfeffer MA, Moye LA et al. [books.google.com]

Treatment consists of anticoagulants. Endocarditis usually refers to infection of the endocardium (ie, infective endocarditis ). [merck.com]

Prognosis The yearly rate for occurrence of SUD in people less than 35 years of age is less than 7 incidents per 100,000. Of all SUD cases, only about 8% are exercise related. [medical-dictionary.thefreedictionary.com]

Prognosis is generally poor, more because of the seriousness of predisposing disorders than the cardiac lesion. Treatment consists of anticoagulation with heparin (either intravenous unfractionated or subcutaneous low molecular weight). [merck.com]

Xian Li and Xianglin Cheng, Application of T-Wave Alternans in Evaluation of Prognosis in Patients with Intracerebral Hemorrhage, Yangtze Medicine, 01, 03, (127), (2017). [dx.doi.org]

Prevalence and prognosis of exercise-induced nonsustained ventricular tachycardia in apparently healthy volunteers. Am J Cardiol. 1984 Oct 1;54(7):762-4. [24]-Atwal S, Porter J, MacDonald P. [afpafitness.com]

View/Print Table TABLE 2 Likely Etiologies for Sudden Cardiac Death in Young Athletes Hypertrophic cardiomyopathy Coronary artery anomalies Atherosclerotic coronary artery disease Myocarditis Other etiologies (less common) Right ventricular dysplasia [aafp.org]

The etiological diagnosis is, however, essential. Indeed, giving medical clearance for sports participation to a patient with heart disease exposes that athlete to an elevated risk of an adverse cardiac event. [aspetar.com]

Although some of this mortality risk is attributable to suicide, many deaths are likely cardiovascular in etiology. [dx.doi.org]

We really don’t know, but I think the observation, based on epidemiologic data, is valid,” he said. Proposed multifactorial mechanisms for the increased incidence of AF in aging endurance athletes hinge in part upon basic science studies. [mdedge.com]

"Significant evidence supports that athletes are "different" from nonathletes from the epidemiological, physiological, evaluation, and management perspectives, with significant heterogeneity among athlete subgroups. [athleticheartsf.com]

The use of screening tests, however, should be evaluated by epidemiologic criteria for determining effectiveness, not merely by media and/or public consensus. [aafp.org]

Everything here on out is epidemiology and public health concerns. There are three major studies of screening procedures serving as the predominant source of data in this argument. [jessefredeen.kinja.com]

Epidemiology and prognostic implications of syncope in young competing athletes. Eur Heart J. 2004 ; 25 :1749–1753. Crossref Medline Google Scholar 109. Basso C, Maron BJ, Corrado D, Thiene G. [circ.ahajournals.org]

1243 Percutaneous Coronary Intervention 1258 Percutaneous Cardiac Procedures 1273 Coronary Artery Bypass Surgery 1290 Approaches to the Patient with Prior Bypass Surgery 1306 Percutaneous Valve Dilatations 1316 Global Pandemic of Heart Failure 1330 Pathophysiology [books.google.com]

ATHLETE’S HEART DETERMINANTS The athlete’s heart pathophysiology is multifactorial 1. As with skeletal muscle, exercise modulates expression of the genome part which encodes for structural and metabolic proteins of the cardiovascular system. [aspetar.com]

Obesity cardiomyopathy: pathophysiology and evolution of the clinical syndrome. Am J Med Sci 2001; 321: 225–36 PubMed CrossRef Google Scholar 34. Opie LH, Commerford PJ, Gersh BJ, et al. Controversies in ventricular remodeling. [doi.org]

It is not proven that ECG screening will prevent athlete sudden cardiac death. Pre-participation ECGs may increase false alarms for some athletes. Sports may not worsen all conditions, and we can’t prevent all deaths. [utswmedicine.org]

Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. ‏ [books.google.com]

Preventing Sudden Death in Young Athletes The sudden death of a young athlete is a tragic event that has devastating effects on families and communities. [barnesjewish.org]

“To prevent one death in the U.S., where there’s a lower rate of inherited heart conditions that lead to sudden cardiac arrest, you’d have to stop almost 2,000 kids from playing sports,” he added. [today.com]

1. Scharhag J, Löllgen H, Kindermann W. Competitive Sports and the Heart: Benefit or Risk? Dtsch Arztebl Int. 2013;110(1-2):14-24.
2. Khan AA, Safi L, Wood M. Cardiac Imaging In Athletes. Methodist Debakey Cardiovasc J. 2016;12(2):86-92.
3. Riding NR, Salah O, Sharma S, et al. Do big athletes have big hearts? Impact of extreme anthropometry upon cardiac hypertrophy in professional male athletes. Br J Sports Med. 2012;46(1):i90-i97.
4. Fagard R. Athlete’s heart. Heart. 2003;89(12):1455-1461.
5. Caselli S, Maron MS, Urbano-Moral JA, Pandian NG, Maron BJ, Pelliccia A. Differentiating left ventricular hypertrophy in athletes from that in patients with hypertrophic cardiomyopathy. Am J Cardiol. 2014;114(9):1383–1389.
6. Biffi A, Pelliccia A, Verdile L, et al. Long-term clinical significance of frequent and complex ventricular tachyarrhythmias in trained athletes. J Am Coll Cardiol. 2002;40:446–452.
7. Afonso L, Kondur A, Simegn M, et al. Two-dimensional strain profiles in patients with physiological and pathological hypertrophy and preserved left ventricular systolic function: a comparative analyses. BMJ Open. 2012;2(4):e001390.
8. Basavarajaiah S, Boraita A, Whyte G, et al. Ethnic differences in left ventricular remodeling in highly-trained athletes relevance to differentiating physiologic left ventricular hypertrophy from hypertrophic cardiomyopathy. J Am Coll Cardiol. 2008;51:2256–2262.