Summary
Assessment of echocardiographic measurements in athletes should take into account the specific sport and the quantity and quality of training. In addition, values corrected for body dimensions, especially the active body mass, should be used rather than absolute values. All parts of the athlete’s heart are enlarged and its performance increases. Highly trained endurance athletes show the most enlarged hearts. Athlete’s heart can be observed in athletes of all ages including the young. However, it is rarer than generally assumed.
To differentiate between physiological and pathological myocardial changes, the relationship between heart size and ergometric performance as well as the echocardiographically measured ratio between left ventricular (LV) myocardial thickness and volume are useful; the latter remains unchanged, on the whole, in endurance- and strength-trained athletes.
Concentric hypertrophy cannot be induced by strength training alone; additional factors, such as hypertension, aortic stenosis, cardiomyopathy or anabolic steroid use can play an important role. When corrected for body dimensions, non-endurance-trained, e.g. strength-trained, athletes have standard heart sizes even if considerable time is devoted to training.
Findings in healthy untrained persons with large body dimensions also indicate no significant difference between the increase of echocardiographic measures caused by training and that caused by growth. An LV myocardial thickness of 13mm is seldom exceeded even in the highly endurance-trained or anabolic drug-free strength trained athletes under physiological conditions. However, the echocardiographic differentiation of cardiomyopathy can be difficult if an individual is highly trained and has large body dimensions. In such cases, LV end-diastolic diameter may be up to 66 to 70mm. The upper normal value of LV muscle mass is 170 g/m2 for a physiological heart enlargement.
Future areas of investigation should include: adaptative changes; of the right ventricle; differences in the regression of the athlete’s heart after cessation of training; the differentiation between echocardiographic changes; in highly endurance-trained or combined strength-endurance-trained persons and pathological changes; the importance of heart size and endurance sports performance; and finally the influence of genetic factors.
Similar content being viewed by others
References
Alén M, Häkkinen K, Komi PV. Changes in neuromuscular performance and muscle fiber characteristics of elite power athletes self-administering androgenic and anabolic steroids. Acta Physiologica Scandinavica 122: 535–544, 1984
American College of Sports Medicine. Position stand on the use of anabolic androgenic steroids in sports. Sports Medicine Bulletin 19: 13–18, 1984
Appell HJ, Heller-Umpfenbach B, Feraudi M, Weicker H. Ultra-structural and morphometric investigations on the effects of training and administration or anabolic steroids on the myocardium of guinea pigs. International Journal of Sports Medicine 4: 268–274, 1983
Behrendt H, Boffin H. Myocardial cell lesions caused by anabolic hormone. Cell and Tissue Research 181: 423–426, 1977
Blasius R, Käsfer K, Seitz W. Untersuchungen über die Abhängigkeit von androgener Wirkung und proteinaufbauendem Effekt der Steroid-Hormone auf die contractilen Muskelproteine des Herzens. Klinische Wochenschrift 35: 308–310, 1957
Bodem R, Albig M, Darwich D. Kardiale Befunde bei Patienten mit Akromegalie: eine echokardiographische Studie. Zeitschrift für Kardiologie 67: 163–170, 1978
Brown S, Byrd R, Jayasinghe MD, Jones D. Echocardiographic characteristics of competitive and recreational weight lifters. Journal of Cardiovascular Ultrasonography 2: 163–165, 1983
Child J, Barnard R. Noninvasive evaluation of cardiac hypertrophy and function in master endurance runners and sprinters Abstract. Medicine and Science in Sports and Exercise 11: 82, 1979
Cohen JL, Segal KR. Left ventricular hypertrophy in athletes: an exercise-echocardiographic study. Medicine and Science in Sports and Exercise 17: 695–700, 1985
Colan SD, Sanders SP, Borow KM. Physiologic hypertrophy: effects on left ventricular systolic mechanics in athletes. Journal of American College of Cardiology 9: 776–783, 1987
Colan SD, Sanders SP, MacPherson D, Borow KM. Left ventricular diastolic function in elite athletes with physiologic cardiac hypertrophy. Journal of American College of Cardiology 6: 545–549, 1985
Colliander EB, Tesch PA. Blood pressure in resistance-trained athletes. Canadian Journal of Applied Sport Sciences 13: 31–34, 1988
DeMaria AN, Neumann A, Schubart PJ, Lee G, Mason DT. Systematic correlation of cardiac chamber size and ventricular performance determined with echocardiography and alterations in heart rate in normal persons. American Journal of Cardiology 43: 1–9, 1979
DeMaria AN, Neumann A, Lee G, Fowler W, Mason DT. Alterations in ventricular mass and performance induced by exercise training in man evaluated by echocardiography. Circulation 57: 237–244, 1978
Devereux RB, Reichek N. Echocardiographic determination of left ventricular mass in man: anatomic validation of the method. Circulation 55: 613–618, 1977
Dickhuth HH, Jakob E, Staiger J, Keul J. Echokardiographische Befunde beim Sportherz. In Rost R & Webering F (Eds) Kardiologie im Sport, pp. 132–145, Deutscher Arzte-Verlag, Cologne, 1987
Dickhuth HH, 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. International Journal of Sports Medicine 4: 21–26, 1983
Dickhuth HH, Simon G, Kindermann W, Wildberg A, Keul J. Echocardiographic studies on athletes of various sport-types and non-athletic persons. Zeitschrift für Kardiologie 68: 449–453, 1979
Dickhuth HH, Horstmann T, Staiger J, Reindell H, Keul J. The long-term involution of physiological cardiomegaly and cardiac hypertrophy. Medicine and Science in Sports and Exercise 21: 244–249, 1989
Dickhuth HH, Jakob E, Wink K, Bonzel T, Keul J, et al. Lässt sich aus der maximalen physiologischen Herzhypertrophie ein absolutes kritisches Herzgewicht ableiten? In Franz et al. (Eds) Training und Sport zur Prävention und Rehabilitation in der technisierten Umwelt, pp. 722–727, Springer, Berlin, 1985
Douglas PS, O’Toole ML, Hiller DB, Reichek N. Left ventricular structure and function by echocardiography in ultraendurance athletes. American Journal of Cardiology 58: 805–809, 1986
Effron MB. Effects of resistive training on left ventricular function. Medicine and Science in Sports and Exercise 21: 694–697, 1989
Ehsani AA, Hagberg JM, Hickson RC. Rapid changes in left ventricular dimensions and mass in response to physical conditioning and deconditioning. American Journal of Cardiology 41: 52–56, 1978
Emmerich J, Steim H, Klepzig H, Musshoff K, Reindell H, Baumgarten B. Über den Einfluss blutiger Untersuchungsmethoden auf das Herzzeitvolumen. Zeitschrift für Kreislauft-Forschung 47: 326, 1958
Fagard R, Aubert A, Lysens R, Staessen J, Vanhees L, Amery A. Noninvasive assessment of seasonal variations in cardiac structure and function in cyclists. Circulation 67: 896–901, 1983
Feigenbaum HL. Echocardiography, Lea and Febiger, Philadelphia, 1981
Reck SJ. Cardiovascular adaptations to resistance training. Medicine and Science in Sports and Exercise 20 (Suppl): S146–S151, 1988
Fleck SJ, Henke C, Wilson W. Cardiac MRI of elite junior Olympic weight lifters. International Journal of Sports Medicine 10: 329–333, 1989
Fouad FM, Tarazi RC, Gallagher JH, Macintyre WJ, Cook SA. Abnormal left ventricular relaxation in hypertensive patients. Clinical Science 59: 411–414, 1980
Gibson DG, Traill TA, Hall RJC, Brown DJ. Echocardiographic features of secondary left ventricular hypertrophy. British Heart Journal 41: 54–59, 1979
Gilbert BW, Pollick C, Adelman AG, Wigle ED. Hypertrophic cardiomyopathy: subclassification by M mode echocardiography. American Journal of Cardiology 45: 861–872, 1980
Hanrath P, Mathey DG, Siegert R, Bleifeld W. Left ventricular relaxation and filling pattern in different forms of left ventricular hypertrophy: an echocardiographic study. American Journal of Cardiology 45: 15–23, 1980
Hauser AM, Dressendorfer RH, Vos M, Hashimoto T, Gordon S, Timmis GC. Symmetric cardiac enlargement in highly trained endurance athletes: a two-dimensional echocardiographic study. American Heart Journal 109: 1038–1044, 1985
Henry WL, Clark CE, Epstein SE. Asymmetric septal hypertrophy: echocardiographic identification of the pathognomonic anatomic abnormality of IHSS. Circulation 47: 225–233, 1973
Henry WL, Ware J, Gardin JM, Hepner SI, McKay J, Weiner M. Echocardiographic measurements in normal subjects: growth-related changes that occur between infancy and early adulthood. Circulation 57: 278–285, 1987
Henschen S. Skilanglauf und Skiwettlauf: eine medizinische Sportstudie. Mitteilung Medizinische Klinik, Upsala, Fischer, Jena, 1899
Höglund C. Enlarged left atrial dimension in former endurance athletes: an echocardiographic study. International Journal of Sports Medicine 7: 133–136, 1986
Hollmann W. Körperliches Training als Prävention von Herz-Kreislaufkrankheiten, Hippokrates, Stuttgart, 1965
Inouye I, Massie B, Loge D, Topic N, Silverstein D, et al. Abnormal left ventricular filling: an early finding in mild to moderate systemic hypertension. American Journal of Cardiology 53: 120–126, 1984
Keul J, Dickhuth HH, Simon G, Lehmann M. Effect of static and dynamic exercise on heart volume, contractility and left ventricular dimensions. Circulation Research 48 (Suppl. 1): 162–170, 1981
Kindermann W, Keul J, Reindell H. Grundlagen zur Bewertung leistungsphysiologischer Anpassungsvorgange. Deutsche Medizinische Wochenschrift 99: 1372–1379, 1974
Kindermann W, Keul J, Simon G, Reindell H. Anpassungserscheinungen durch Schul- und Leistungssport im Kindesalter. Sportwissenschaft 8: 222–234, 1978
Kindermann W, Urhausen A. Das Sportherz und seine Abgrenzung. Fortschritte der Medizin 109: 41–46, 1991
Lecarpentier Y, Martin JL, Chemla D, Dos Santos A, Grillon G, et al. Relaxation of mammalian heart muscle during chronic cardiac overload. European Heart Journal 5 (Suppl. F): 37–42, 1984
Linzbach AJ. Herzhypertrophie und kritisches Herzgewicht. Klinische Wochenschrift 26: 459, 1948
Longhurst JC, Kelly AR, Gonyea WJ, Mitchell JH. Echocardiographic left ventricular masses in distance runners and weight lifters. Journal of Applied Physiology 48: 154–162, 1980
Maron BJ. Structural features of the athletes heart as defined by echocardiography. Journal of the American College of Cardiology 7: 190–203, 1986
Maron BJ, Roberts WC, McAllister HA, Rosing DR, Epstein SE. Sudden death in young athletes. Circulation 62: 218–229, 1980
Matsuda M, Sugishita Y, Koseki S, Iko I, Akatsuka T, et al. Effect of exercise on left ventricular diastolic filling in athletes and nonathletes. Journal of Applied Physiology 55: 323–338, 1983
McDougall JD, Tuxen D, Sale DG, Moroz JR, Sutton JR. Arterial pressure response to heavy resistance exercise. Journal of Applied Physiology 58: 785–789, 1985
Medved R, Pavisit V, Stuka K. Das grösste gesunde Sportherz bei Frauen. Sportarzt und Sportmedizin 26: 174–176, 1975
Menapace FJ, Hammer WJ, Ritzer TF, Kessler KM, Warner HF, et al. Left ventricular size in competitive weight lifters: an echocardiographic study. Medicine and Science in Sports and Exercise 14: 72–75, 1982
Morganroth J, Maron BJ, Henry WL, Epstein SE. Comparative left ventricular dimensions in trained athletes. Annals of Internal Medicine 82: 521–524, 1975
Musshoff K, Reindell H. Zur Röntgenuntersuchung des Herzens in horizontaler und vertikaler Körperstellung. I. Mitteilung: der Einfluss der Körperstellung auf das Herzvolumen. Deutsche Medizinische Wochenschrift 81: 1001, 1956
Nishimura T, Yamada Y, Kawai C. Echocardiographic evaluation of long-term effects of exercise on left ventricular hypertrophy and function in professional bicyclists. Circulation 61: 832–840, 1980
Pearson AC, Labovitz AJ, Windhorst D, Williams GA. Doppler echocardiography in the assessment of diastolic filling in normal and hypertrophied hearts. Abstract. Clinical Research 34: 335A, 1986
Pearson AC, Schiff M, Mrosek D, Labovitz AJ, Williams GA. Left ventricular diastolic function in weight lifters. American Journal of Cardiology 58: 1254–1259, 1986
Pellicia A, Maron BJ, Spataro A, Proschan MA, Spirito P. The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes. New England Journal of Medicine 324: 295–301, 1991
Péronnet F, Perrault H, Cléroux J, Cousineau D, Nadeau R, et al. Electro- and echocardiographic study of the left ventricle in man after training. European Journal of Applied Physiology 45: 125–130, 1980
Reindell H, Dickhuth HH. Das Sportherz. In Reindell et al. (Eds) Funktionsdiagnostik des gesunden und kranken Herzens, pp. 95–111, Thieme, Stuttgart, 1988
Reindell H, Kindermann W, Dickhuth HH, Simon G. Das Sportherz. In Blumchen (Ed.) Beiträge zur Geschichte der Kardiologie, pp. 89–110, Roderbirken, 1979
Reindell H, Klepzig H, Steim H, Musshoff K, Roskamm H, et al. Herz-Kreislaufkrankheiten und Sport, Barth, Munich, 1960
Ricci G, Lajoie D, Petitclerc R, Péronnet F, Ferguson RJ, et al. Left ventricular size following endurance, sprint and strength training. Medicine and Science in Sports and Exercise 14: 344–347, 1982
Roeske WR, O’Rourke RA, Klein A, Leopold G, Karliner JS. Noninvasive evaluation of ventricular hypertrophy in professional athletes. Circulation 53: 286–292, 1976
Rost R. Das Herz des Sportlers im Ultraschall, Hofmann, Schorndorf, 1982
Rost R, Hollman W. Athlete’s heart — a review of it’s historical assessment and new aspects. International Journal of Sports Medicine 4: 147–165, 1983
Rost R, Kusber M, Bjarnason-Wehrens B, Tiberi M. Untersuchungen zur Problematik der Talentauswahl aus internistischer Sicht. In Boning et al. (Eds) Sport: Rettung oder Risiko tur die Gesundheit? pp. 988–991, Deutscher Ärzte-Verlag, Cologne, 1989
Roy A, Doyon M, Dumesnil JG, Jobin J, Landry F. Endurance vs strength training: comparison of cardiac structures using normal predicted values. Journal of Applied Physiology 64: 2552–2557, 1988
Salke RC, Rowland TW, Burke EJ. Left ventricular size and function in body builders using anabolic steroids. Medicine and Science in Sports and Exercise 17: 701–704, 1985
Saltin B, Blomqvist G, Mitchell JH, Johnson RL, Wildenthal K, Chapman CB. Response to submaximal and maximal exercise after bed rest and training. Circulation 38 (Suppl. 7): 1–78, 1968
Schaible TF, Scheuer J. Cardiac adaptations to chronic exercise. Progress in Cardiovascular Diseases 27: 297–324, 1985
Shapiro LM, McKenna WJ. Left ventricular hypertrophy. Relation of structure to diastolic function in hypertension. British Heart Journal 51: 637–642, 1984
Shapiro LM. Physiological left ventricular hypertrophy. British Heart Journal 52: 120–135, 1984
Simon G, Staiger J, Wehninger A, Kindermann W, Keul J. Echokardiographische Grössen des linken Ventrikels, Herzvolumen und Sauerstoffaufnahme. Medizinische Klinik 73: 1457–1462, 1978
Snoeckx LHEH, Abeling HFM, Lambregts JAC, Schmitz JJF, Verstappen FTJ, Renemann RS. Echocardiographic dimensions in athletes in relation to their training programs. Medicine and Science in Sports and Exercise 14: 428–434, 1982
Staiger J, Braun R, Dickhuth HH, Keul J. Diagnose der Herzhypertrophie durch Echokardiographie im Vergleich zu Autopsieergebnissem Herz-Kreislauf 21: 111–117, 1989
Staiger J, Braun R, Jaedicke J, Wink K, Dickhuth HH. Nichtinvasive Bestimmung der diastolischen Ventrikelfunktion aus dem Echokardiogramm. Herz-Kreislauf 15: 388–392, 1983
Sugishita Y, Koseki S, Matsuda M, Yamaguchi T, Ito I. Myocardial mechanics of athletic hearts in comparison with diseased hearts. American Heart Journal 105: 273–280, 1983
Troy BL, Pombo J, Rackley CE. Measurement of left ventricular wall thickness and mass by echocardiography. Circulation 45: 602–611, 1972
Ullrich I, Younis M, Yeater R, Borsch M, Zanke C. Cardiac hypertrophy in weight lifters: only in steroid users? Medicine and Science in Sports and Exercise 22 (Suppl.): S64, 1990
Urhausen A, Erpelding JR, Kindermann W. Beurteilung von echokardiographischen Parametern unter Berücksichtigung der Körperdimensionen. In Jeschke and Bernett (Eds) Pro und Contra — Sport und Medizin. Proceedings of the 32nd German Congress of Sports Medicine, Munich 1990 (in press).
Urhausen A, Hölpes R, Kindermann W. One- and two-dimensional echocardiography in bodybuilders using anabolic steroids. European Journal of Applied Physiology 58: 633–640, 1989
Urhausen A, Kindermann W. Ein- und zweidimensionale echokardiographische Herzvolumenbestimmung bei Herzgesunden im Vergleich zur röntgenologischen Methode und zu spiroergometrischen Parametern. Herz-Kreislauf 19: 525–528, 1987
Urhausen A, Kindermann W. One- and two-dimensional echocardiography in body builders and endurance-trained subjects. International Journal of Sports Medicine 10: 139–144, 1989
Van Den Broeke C, Fagard R. Left ventricular structure and function, assessed by imaging and doppler echocardiography, in athletes engaged in throwing events. International Journal of Sports Medicine 9: 407–411, 1988
Völker K, Rödder E, Hollmann W. Das Blutdruckverhalten bei Bodybuildern. Deutsche Zeitschrift für Sportmedizin 39: 4–8, 1988
Vollmer-Larsen A, Vollmer-Larsen B, Kelbaek H, Godfredsen J. The veteran athlete: an echocardiographic comparison of veteran cyclists, former cyclists and non-athletic subjects. Acta Physiologica Scandinavica 135, 393–398, 1989
Walter R, Schmitt W, Kindermann W. Differentialdiagnose der Herzvergrösserung — Bedeutung der Sportanamnese zur Abgrenzung der physiologischen und der pathologischen Herzvergrösserung. In Franz et al. (Eds) Training und Sport zur Prävention und Rehabilitation in der technisierten Umwelt, pp. 716–721, Springer, Berlin, 1985
Weicker H, Hägele H, Repp B, Kolb J. Influence of training and anabolic steroids on the LDH isozyme pattern of skeletal and heart muscle fibers of guinea pigs. International Journal of Sports Medicine 3: 90–96, 1982
Wieling W, Borghols EAM, Hollander AP, Danner SA, Dunning AJ. Echocardiographic dimensions and maximal oxygen uptake in oarsmen during training. British Heart Journal 46: 190–195, 1981
Wolfe LA, Cunningham DA, Boughner DR. Physical conditioning effects on cardiac dimensions: a review of echocardiographic studies. Canadian Journal of Applied Sport Sciences 11: 66–79, 1986
Wolfe LA, Martin RP, Seip RL. Absence of left ventricular hypertrophy in elite college basketball players. Canadian Journal of Applied Sport Sciences 10: 116–121, 1985
Wolfe LA, Cunningham DA, Rechnitzer PA, Nichol PM. Effects of endurance training on left ventricular dimensions in healthy men. Journal of Applied Physiology 47: 207–212, 1979
Zuliani U, Bernardinin B, Catapano A, Campana M, Cerioli G, Spattini M. Effects of anabolic steroids, testosterone, and HGH on blood lipids and echocardiographic parameters in bodybuilders. International Journal of Sports Medicine 10: 62–66, 1989
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Urhausen, A., Kindermann, W. Echocardiographic Findings in Strength- and Endurance-Trained Athletes. Sports Medicine 13, 270–284 (1992). https://doi.org/10.2165/00007256-199213040-00004
Published:
Issue Date:
DOI: https://doi.org/10.2165/00007256-199213040-00004