Differentiating an Athlete’s Heart and Cardiomyopathy
Key result
Multimodality imaging differentiates pathological cardiomyopathy from physiological remodeling to guide targeted therapy and safe exercise.
- n=1
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Why the study?
Athletes can develop adaptive cardiac remodeling that overlaps with cardiomyopathy, and cases with diagnostic uncertainty may require advanced imaging to guide management.
Key Points
- To evaluate the role of multimodality cardiac imaging in distinguishing benign exercise-induced cardiac remodeling from pathological cardiomyopathy in an endurance athlete.
- Clinical, electrocardiographic, and multimodality imaging evaluations—including echocardiography, cardiac magnetic resonance (CMR), and FDG-PET—were performed in a 37-year-old male endurance athlete (N=1).
- Further assessment included ambulatory rhythm monitoring, cardiopulmonary exercise testing (CPET), genetic screening, and a 6-month period of exercise cessation before initiating medical therapy.
- CMR revealed multifocal late gadolinium enhancement spanning 6 segments (5% of left ventricular mass) with subepicardial, papillary muscle, and right ventricular septal involvement, exceeding typical physiological remodeling.
- Initiation of guideline-directed medical therapy (sacubitril/valsartan, spironolactone, and empagliflozin) combined with a graded return to exercise resulted in stable clinical status without ventricular arrhythmias at 6-month follow-up.
Study Design
Type
Case Report (n=1)
Structured PICO
P
Population
A 37-year-old male endurance athlete with incidental cardiac enlargement evaluated with multimodality imaging to differentiate physiological remodeling from cardiomyopathy, followed for 6 months.
I
Intervention
Multimodality imaging (CMR, FDG-PET, CPET) and initiation of guideline-directed medical therapy (sacubitril/valsartan 24/26 mg twice daily, spironolactone 12.5 mg daily, empagliflozin 10 mg daily).
Multimodality imaging can provide critical diagnostic insights to differentiate physiological athletic remodeling from cardiomyopathy, guiding individualized medical therapy and safe return to exercise.
Limitations
- Lack of evidence to institute guideline-directed medical therapy in this specific patient scenario
- An element of uncertainty remained regarding the definitive diagnosis
- Lack of evidence to institute GDMT in this patient scenario
- Element of uncertainty regarding definitive diagnosis
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Answers are grounded in this paper and cite their sources.
Implication
May support multimodality imaging in ambiguous athlete evaluations; leaves open prospective validation before broader adoption.
Abstract
BACKGROUND: Athletes can develop multifaceted adaptive cardiac remodeling with features overlapping with cardiomyopathy. Although clinical evaluation and echocardiography usually suffice in assessment, cases with uncertainty may benefit from advanced imaging to clarify the diagnosis and management. CASE SUMMARY: A 37-year-old male endurance athlete was referred after a screening coronary calcium scan incidentally revealed cardiac enlargement. Electrocardiography and echocardiography suggested exercise-induced physiological remodeling; however, cardiac magnetic resonance imaging revealed multifocal myocardial scarring concerning for cardiomyopathy. He underwent a comprehensive evaluation, was initiated on guideline-directed medical therapy, and ultimately resumed exercise through shared decision-making. DISCUSSION: Advanced cardiac imaging is valuable when distinguishing an athlete's heart from cardiomyopathy is uncertain and supports individualized management decisions regarding safe exercise participation. TAKE-HOME MESSAGES: Distinguishing physiological remodeling from cardiomyopathy in athletes can be challenging. Multimodality imaging can provide important diagnostic insights and guide individualized management, but its use should be judicious and findings should be interpreted with caution.
JACC Case Reports · case report. In one athlete, multimodality imaging flagged cardiomyopathy, guiding safe return to exercise. Differentiating an Athlete’s Heart and Cardiomyopathy 37-year-old athlete, incidental cardiac enlargement: Endurance athlete, Hyperlipidemia, Prior COVID-19, Enlarged heart. Three tests to separate adaptation from disease: CMR → FDG-PET → CPET. 5% of LV mass: Multifocal scar across 6 segments, beyond athletic remodeling. GDMT plus a graded return to exercise: Sacubitril/valsartan, Spironolactone, Empagliflozin, Graded exercise. 6 months: Stable, no ventricular arrhythmias, exercising again. Bottom line: In ambiguous athletes, multimodality imaging may help separate cardiomyopathy from remodeling.
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Cite This Study
Jilani et al. (2026) conducted a case report in Athlete's heart vs cardiomyopathy (n=1). Multimodality cardiac imaging and guideline-directed medical therapy was evaluated. Advanced multimodality imaging revealed multifocal myocardial scarring, distinguishing underlying cardiomyopathy from physiological remodeling and guiding individualized management and safe return to exercise.