Comment on: “Athlete’s Heart: Diagnostic Challenges and Future Perspectives”

  • Wilfried Kindermann
  • Axel Urhausen
  • Jürgen Scharhag
Letter to the Editor

Dear Editor,

The athlete’s heart has been a diagnostic challenge for many decades. In an interesting review, the authors present strategies to differentiate exercise-induced physiological from pathological cardiac changes [1]. It is emphasized that the athlete’s heart is characterized by a biventricular remodeling, regardless of the type of sports. We would like to comment on a few issues.

The diagnostic procedure presented in Fig. 1 is debatable, while the order of diagnostic tools is adequately presented in Table 2 [1]. If the first-line examinations including resting electrocardiogram (ECG) are abnormal, the next step should be exercise ECG, possibly combined with cardiopulmonary exercise testing (CPET). Unfortunately, the importance of ECG stress testing was hardly mentioned. The exercise ECG can be useful to detect arrhythmias and especially in middle-aged and older athletes to identify coronary heart disease [2]. The diagnostic accuracy of exercise ECG in athletes, however, is...


Compliance with Ethical Standards

Conflict of interest

The authors—Wilfried Kindermann, Axel Urhausen, and Jürgen Scharhag—declare that they have no conflicts of interest.


No funding was received for the publication of this letter.


  1. 1.
    De Innocentiis C, Ricci F, Khanji MY, Aung N, Tana C, Verrengia E, et al. Athlete’s heart: diagnostic challenges and future perspectives. Sports Med. 2018;48(11):2463–77.CrossRefGoogle Scholar
  2. 2.
    Sofi F, Capalbo A, Pucci N, Giuliattini J, Condino F, Alessandri F, et al. Cardiovascular evaluation, including resting and exercise electrocardiography, before participation in competitive sports: cross sectional study. BMJ. 2008;337:a346.CrossRefGoogle Scholar
  3. 3.
    Claessen G, Schnell F, Bogaert J, Claeys M, Pattyn N, De Buck F, et al. Exercise cardiac magnetic resonance to differentiate athlete’s heart from structural heart disease. Eur Heart J Cardiovasc Imaging. 2018;19(9):1062–70.CrossRefGoogle Scholar
  4. 4.
    Maron BJ, 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(5):1596–601.CrossRefGoogle Scholar
  5. 5.
    La Gerche A, Baggish A, Heidbuchel H, Levine BD, Rakhit D. What may the future hold for sports cardiology? Heart Lung Circ. 2018;27(9):1116–20.CrossRefGoogle Scholar
  6. 6.
    Dickhuth HH, Röcker K, Hipp A, Heitkamp HC, 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;15(5):273–7.CrossRefGoogle Scholar
  7. 7.
    Morganroth J, Maron BJ, Henry WL, Epstein SE. Comparative left ventricular dimensions in trained athletes. Ann Intern Med. 1975;82(4):521–4.CrossRefGoogle Scholar
  8. 8.
    Baggish AL, Weiner RB, Kanayama G, Hudson JI, Lu MT, Hoffmann U, et al. Cardiovascular toxicity of illicit anabolic-androgenic steroid use. Circulation. 2017;135(21):1991–2002.CrossRefGoogle Scholar
  9. 9.
    Karila TA, Karjalainen JE, Mäntysaari MJ, Viitasalo MT, Seppälä TA. Anabolic androgenic steroids produce dose-dependant increase in left ventricular mass in power athletes, and this effect is potentiated by concomitant use of growth hormone. Int J Sports Med. 2003;24(5):337–43.CrossRefGoogle Scholar
  10. 10.
    De Piccoli B, Giada F, Benettin A, Sartori F, Piccolo E. Anabolic steroid use in body builders: an echocardiographic study of left ventricle morphology and function. Int J Sports Med. 1991;12(4):408–12.CrossRefGoogle Scholar
  11. 11.
    Urhausen A, Hölpes R, Kindermann W. One- and two-dimensional echocardiography in bodybuilders using anabolic steroids. Eur J Appl Physiol Occup Physiol. 1989;58(6):633–40.CrossRefGoogle Scholar
  12. 12.
    Urhausen A, Kindermann W. Sports-specific adaptations and differentiation of the athlete’s heart. Sports Med. 1999;28(4):237–44.CrossRefGoogle Scholar
  13. 13.
    Urhausen A, Albers T, Kindermann W. Are the cardiac effects of anabolic steroid abuse in strength athletes reversible? Heart. 2004;90(5):496–501.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Institute of Sports and Preventive MedicineSaarland UniversitySaarbrückenGermany
  2. 2.Médecine du Sport et de PreventionCentre de Hospitalier LuxemburgLuxembourgLuxembourg
  3. 3.Sports and Exercise PhysiologyUniversity ViennaViennaAustria

Personalised recommendations