Echocardiographic predictors of athlete performance: a comparative analysis across different training profiles

Background Exercise impacts cardiac structure and function, leading to adaptive remodeling known as "athlete's heart." Assessing myocardial function can be challenging, as ejection fraction (EF) and global longitudinal strain (GLS) often fall at the lower end of normal. Purpose This study investigated standard and advanced echocardiographic parameters in endurance athletes with different training profiles, assessing their association with performance. Methods Consecutive endurance athletes undergoing cardiological screening or orthopedic evaluation for knee injuries were evaluated using echocardiography and cardiopulmonary exercise testing. Athletes were categorized into three groups: (1) Long-Distance (n=30), competing in marathons and ultramarathons; (2) Mid-Distance (n=27), competing in middle-distance races; and (3) Detrained (n=31), with ≥6 months of forced training interruption. Results Left ventricular ejection fraction did not differ among groups. The Long-Distance group had the highest stroke volume index (SVi), followed by the Mid-Distance and Detrained groups (p<.001). Long-Distance athletes showed lower left ventricular global longitudinal strain (GLS) (p=.003) and left atrial reservoir strain (p=.003) compared to the other groups, while no differences were observed in right ventricular free wall strain. Myocardial work (MW) analysis revealed a higher work index, constructive work, and lower wasted work, leading to greater MW efficiency in the Long-Distance group (p<.001). In multivariable analysis, both SVi (β=1.03, p<.001) and MW efficiency (β=0.891, p=.008) were independently associated with Peak VO2, whereas GLS was not. Conclusion Advanced echocardiography provides additional insights into the athlete’s heart, with MW indices proving more sensitive than GLS in differentiating training-induced cardiac adaptations. Similarly, left atrial reservoir strain is influenced by training status. SVi and MW efficiency emerged as reliable predictors of performance. These findings support the integration of advanced echocardiographic parameters for athlete monitoring and differentiation from pathological conditions.Graphical Abstract Advanced Echo Parameters