Athlete’s heart syndrome: A diagnostic dilemma in the emergency department

Athletic training can cause morphological cardiac changes as part of physiological adaptation. When these changes result in abnormalities of physical examination, the electrocardiogram, chest radiography or echocardiographic findings the individual is said to have athlete’s heart syndrome. Many of these changes mimic significant cardiovascular disease, including myocardial ischaemia, hypertrophic cardiomyopathy (the most common cause of sudden cardiac death), dilated cardiomyopathy and pericarditis. Recognizing and distinguishing physiological changes from significant cardiovascular disease is extremely important in an emergency medicine setting. Inappropriate or withheld treatment can affect morbidity and mortality significantly; detection of genuine cardiovascular disease usually requires exclusion from athletic competition to reduce the risk of sudden death. A number of criteria and methods have been proposed to assist in the task of differentiating physiological from pathological changes. Three case reports of ultra‐endurance athletes, which highlight these dilemmas, are presented. These patients had significant electrocardiogram changes, including marked ST segment elevation, T wave inversion and evidence of left ventricular hypertrophy. This paper discusses the morphological and clinical changes associated with athlete’s heart syndrome and the current criteria and methods available to help differentiate this from cardiovascular disease. In many emergency department situations, a clinical history and examination may be all that is required. More complex cases are best resolved by use of echocardiography. Emergency physicians need to be aware of this syndrome and the diagnostic difficulties they may face when managing such patients.