The development of the athlete's heart is a fascinating phenomenon produced by physiologic adaptations to the increased demands of exercise. The syndrome of the athlete's heart includes cardiac hypertrophy and bradycardia as well as other physiologic and morphologic manifestations. Our purpose is to highlight these manifestations in the young athlete and to discuss the cardiovascular complications that may arise in this patient population. Our ultimate goal is to educate the primary caregiver and thereby facilitate the appropriate evaluation and treatment of cardiovascular findings in young, athletic patients.
Henschen first described the athlete's heart in the late nineteenth century.5 Bryan G., Ward A., Rippe J.M. Athletic heart syndrome Clin Sports Med 1992 ; 11 : 259-272
Cliccare qui per andare alla sezione Riferimenti, 58 Rost R. The athlete's heart: Historical perspectives Cardiol Clin 1992 ; 10 : 197-208
Cliccare qui per andare alla sezione Riferimenti He compared the cardiovascular examination of competitive cross-country skiers with that of sedentary controls. Henschen hypothesized that cardiac enlargement in his cohort of skiers was a normal, beneficial response to exercise. Scientists debated this theory throughout the twentieth century, some arguing that the cardiac enlargement seen in athletes was pathologic dilatation resulting from overexertion, possibly in hearts with pre-existing disease. Henschen's original theory, however, has proved correct.
How are normal adaptations in athletes differentiated from the pathologic? Although physical activity has unquestionably been shown to decrease the risk of cardiovascular disease, there remains a small but definable cardiovascular risk with exercise.55 Ragosta M., Crabtree J., Sturner W.Q. , e al. Death during recreational exercise in the State of Rhode Island Med Sci Sports Exerc 1984 ; 16 : 339-342
Cliccare qui per andare alla sezione Riferimenti, 65 Thompson P.D., Klocke F.J., Levine B.D. , e al. 26th Bethesda Conference Task Force 5: Coronary artery disease J Am Coll Cardiol 1994 ; 24 : 888-893 [cross-ref]
Cliccare qui per andare alla sezione Riferimenti This risk has been underscored by several recent, highly publicized deaths of nationally known athletes. Such events have sensitized physicians and other caregivers to the importance of diagnosing cardiovascular abnormalities in athletes and thereby preventing these exercise complications. The following principles can be applied to the syndrome of the athlete's heart and sudden cardiac death during exercise:
1 | Atherosclerotic coronary artery disease (CAD) is the predominant cause of sudden death during exercise in adults.35 Maron B.J., Mitchell J.H. 26th Bethesda Conference: Recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities J Am Coll Cardiol 1994 ; 24 : 845-899
Cliccare qui per andare alla sezione Riferimenti, 55 Ragosta M., Crabtree J., Sturner W.Q. , e al. Death during recreational exercise in the State of Rhode Island Med Sci Sports Exerc 1984 ; 16 : 339-342
Cliccare qui per andare alla sezione Riferimenti, 65 Thompson P.D., Klocke F.J., Levine B.D. , e al. 26th Bethesda Conference Task Force 5: Coronary artery disease J Am Coll Cardiol 1994 ; 24 : 888-893 [cross-ref]
Cliccare qui per andare alla sezione Riferimenti, 66 Thompson P.D., Funk E.J., Carleton M.D. , e al. Incidence of death during jogging in Rhode Island from 1975 through 1980 JAMA 1982 ; 247 : 2535-2538
Cliccare qui per andare alla sezione Riferimenti, 67 Thompson P.D. Cardiac evaluation of the young or old competitive or recreational athlete Sports Med 1990 ; 2 : 3-19
Cliccare qui per andare alla sezione Riferimenti, 72 Wight J.N., Salem D. Sudden cardiac death and the “athlete's heart” Arch Intern Med 1995 ; 155 : 1473-1480
Cliccare qui per andare alla sezione Riferimenti The risk of acute myocardial infarction and sudden cardiac death is increased in adults during exercise, and physicians should know that athletic adults with symptoms possibly related to cardiac ischemia should be referred to a specialist for prompt evaluation. In contrast, sudden death during exercise in athletes under 30 years of age is rarely related to CAD. 36 Maron B.J., Roberts W.C., McAllister H.A. , e al. Sudden death in young athletes Circulation 1980 ; 83 : 412-421
Cliccare qui per andare alla sezione Riferimenti, 69 VanCamp S.P., Bloor C.M., Mueller F.O. , e al. Nontraumatic sports death in high school and college athletes Med Sci Sports Exerc 1995 ; 27 : 641-647
Cliccare qui per andare alla sezione Riferimenti Cardiac complications in young athletes will be the focus of this review. |
2 | The dimensions of an athlete's heart, adjusted for body size, rarely exceed the upper limits of normal.2 Beckner G.L., Winsor T. Cardiovascular adaptations to prolonged physical effort Circulation 1954 ; 9 : 835-846
Cliccare qui per andare alla sezione Riferimenti, 5 Bryan G., Ward A., Rippe J.M. Athletic heart syndrome Clin Sports Med 1992 ; 11 : 259-272
Cliccare qui per andare alla sezione Riferimenti, 20 George K.P., Wolfe L.A., Burggraf G.W. , e al. Electrocardiographic and echocardiographic characteristics of female athletes Med Sci Sports Exerc 1995 ; 27 : 1362-1370
Cliccare qui per andare alla sezione Riferimenti, 21 Gilbert C.A., Nutter D.O., Felner J.M. , e al. Echocardiographic study of cardiac dimensions and function in the endurance-trained athlete Am J Cardiol 1977 ; 40 : 528-533 [cross-ref]
Cliccare qui per andare alla sezione Riferimenti, 25 Huston T.P., Puffer J.C., Rodney W.M. The athletic heart syndrome N Engl J Med 1985 ; 313 : 24-32 [cross-ref]
Cliccare qui per andare alla sezione Riferimenti, 33 Longhurst J.C., Kelly A.R., Gonyea W.J. , e al. Echocardiographic left ventricular masses in distance runners and weight lifters J Appl Physiol 1980 ; 48 : 154-162
Cliccare qui per andare alla sezione Riferimenti, 37 Maron B.J., Pelliccia A., Spirito P. Cardiac disease in young trained athletes: Insights into methods for distinguishing athlete's heart from structural heart disease, with particular emphasis on hypertrophic cardiomyopathy Circulation 1995 ; 91 : 596-601
Cliccare qui per andare alla sezione Riferimenti, 38 Maron B.J., Pelliccia A., Spataro A. , e al. Reduction in left ventricular wall thickness after deconditioning in highly trained Olympic athletes Br Heart J 1993 ; 69 : 125-128 [cross-ref]
Cliccare qui per andare alla sezione Riferimenti, 39 Maron B.J. Structural features of the athlete heart as defined by echocardiography J Am Coll Cardiol 1986 ; 7 : 190-203 [cross-ref]
Cliccare qui per andare alla sezione Riferimenti, 51 Nishimura T., Yamada Y., Kawai C. Echocardiographic evaluation of long-term effects of exercise on left ventricular hypertrophy and function in professional bicyclists Circulation 1980 ; 61 : 832-840
Cliccare qui per andare alla sezione Riferimenti, 53 Pelliccia A., Maron B.J., Culasso F. , e al. Athlete's heart in women: Echocardiographic characterization of highly trained elite female athletes JAMA 1996 ; 276 : 211-215
Cliccare qui per andare alla sezione Riferimenti, 54 Pelliccia A. Outer limits of physiologic hypertrophy and relevance to the diagnosis of primary cardiac disease Cardiol Clin 1992 ; 10 : 267-279
Cliccare qui per andare alla sezione Riferimenti, 56 Rich B.S.E. Sudden death screening Med Clin North Am 1994 ; 78 : 267-288
Cliccare qui per andare alla sezione Riferimenti, 68 Urhausen A., Kindermann W. Echocardiographic findings in strength and endurance trained athletes Sports Med 1992 ; 13 : 270-284 [cross-ref]
Cliccare qui per andare alla sezione Riferimenti Significant cardiac enlargement usually occurs with repetitive, endurance training. The physiologic changes that occur with this form of training have been extensively studied with echocardiography and advanced cardiac imaging techniques. In the majority of athletes and with only rare exception, changes in left ventricular wall thickness, chamber size, and function remain below the upper limits of normal. 2 Beckner G.L., Winsor T. Cardiovascular adaptations to prolonged physical effort Circulation 1954 ; 9 : 835-846
Cliccare qui per andare alla sezione Riferimenti, 25 Huston T.P., Puffer J.C., Rodney W.M. The athletic heart syndrome N Engl J Med 1985 ; 313 : 24-32 [cross-ref]
Cliccare qui per andare alla sezione Riferimenti, 37 Maron B.J., Pelliccia A., Spirito P. Cardiac disease in young trained athletes: Insights into methods for distinguishing athlete's heart from structural heart disease, with particular emphasis on hypertrophic cardiomyopathy Circulation 1995 ; 91 : 596-601
Cliccare qui per andare alla sezione Riferimenti, 38 Maron B.J., Pelliccia A., Spataro A. , e al. Reduction in left ventricular wall thickness after deconditioning in highly trained Olympic athletes Br Heart J 1993 ; 69 : 125-128 [cross-ref]
Cliccare qui per andare alla sezione Riferimenti, 39 Maron B.J. Structural features of the athlete heart as defined by echocardiography J Am Coll Cardiol 1986 ; 7 : 190-203 [cross-ref]
Cliccare qui per andare alla sezione Riferimenti Hence, few athletes demonstrate cardiac dimensions in the “grey zone” between normal and pathologic cardiac physiology. 37 Maron B.J., Pelliccia A., Spirito P. Cardiac disease in young trained athletes: Insights into methods for distinguishing athlete's heart from structural heart disease, with particular emphasis on hypertrophic cardiomyopathy Circulation 1995 ; 91 : 596-601
Cliccare qui per andare alla sezione Riferimenti |
“Abnormalities” uncovered during the routine cardiac screening of asymptomatic, healthy athletes are usually variants of normal. Identified physical findings are typically manifestations of the athletic heart syndrome. The cardiac adaptations seen with endurance training and described later produce most of the “abnormal” findings.5 Bryan G., Ward A., Rippe J.M. Athletic heart syndrome Clin Sports Med 1992 ; 11 : 259-272
Cliccare qui per andare alla sezione Riferimenti, 25 Huston T.P., Puffer J.C., Rodney W.M. The athletic heart syndrome N Engl J Med 1985 ; 313 : 24-32 [cross-ref]
Cliccare qui per andare alla sezione Riferimenti, 28 Keul J., Dickhuth H.-H., Lehmann M. , e al. The athlete's heart—hemodynamics and structure Int J Sports Med 1982 ; 3 (suppl 1) : 33-43
Cliccare qui per andare alla sezione Riferimenti As mentioned previously, these adaptations rarely exceed the upper limits of normal; however, caregivers of athletes should never ignore cardiac symptoms or significant findings on evaluation.
3. Cardiac symptoms and strikingly abnormal physical findings even in healthy athletes require a prompt evaluation by a cardiovascular expert.16 Fahranbach M.C., Thompson P.D. The preparticipation sports examination: Cardiovascular considerations for screening Cardiol Clin 1992 ; 10 : 319-333
Cliccare qui per andare alla sezione Riferimenti, 35 Maron B.J., Mitchell J.H. 26th Bethesda Conference: Recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities J Am Coll Cardiol 1994 ; 24 : 845-899
Cliccare qui per andare alla sezione Riferimenti, 40 Maron B.J., Thompson P.D., Puffer J.C. , e al. Cardiovascular preparticipation screening of competitive athletes Circulation 1996 ; 94 : 850-856
Cliccare qui per andare alla sezione Riferimenti, 57 Roeske W.R., O'Rourke R.A., Klein A. , e al. Noninvasive evaluation of ventricular hypertrophy in professional athletes Circulation 1976 ; 53 : 286-292
Cliccare qui per andare alla sezione Riferimenti, 67 Thompson P.D. Cardiac evaluation of the young or old competitive or recreational athlete Sports Med 1990 ; 2 : 3-19
Cliccare qui per andare alla sezione Riferimenti Undoubtedly, the most sensitive screening tool for diagnosing a cardiac abnormality in an athlete is the careful history and examination he or she receives prior to athletic participation.
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