Key result
CPET aids in distinguishing athlete's heart from cardiac pathology, but peak oxygen uptake alone proves unreliable.
Why the study?
Distinguishing physiological cardiac adaptation from early or mild cardiac pathology in athletes is challenging, and the diagnostic value of CPET in this context had not been comprehensively synthesized.
CPET provides a valuable functional complement to structural imaging for distinguishing athlete's heart from early cardiomyopathies, provided a multiparametric approach is used rather than relying on peak VO2 alone.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“This manuscript addresses a clinically relevant and increasingly important topic in sports cardiology. The distinction between physiological cardiac adaptation and early manifestations of structural heart disease remains one of the most challenging aspects of evaluating competitive athletes, and the authors have brought together a substantial amount of recent literature in a logical and readable narrative.”
“The authors present a review of the impact of cardiopulmonary exercise testing on the differential diagnosis of athlete's heart and cardiac pathologies. This is a relevant topic in sports cardiology, particularly given the increasing participation in competitive sports and the growing complexity of pre-participation cardiovascular assessment. The manuscript is well organised and provides a balanced overview of the current evidence regarding CPET in cases of cardiomyopathies.”
“More commonly, clinicians encounter athletes with preserved exercise capacity but abnormal ventilatory efficiency, borderline oxygen pulse behaviour, equivocal imaging findings, or isolated exercise-induced ventricular ectopy. These situations represent the true diagnostic challenge in sports cardiology. A brief discussion explaining how the authors approach conflicting CPET variables in the context of borderline imaging findings would substantially increase the practical value of the review.”
Multiparametric CPET may complement imaging in athlete evaluation; leaves open the need for prospective comparative studies across underrepresented groups.
Sports cardiologists frequently face the challenge of distinguishing physiological cardiac adaptation to intensive training (“athlete’s heart”) from early or mild cardiac pathology, a dilemma in which both false-positive and false-negative assessments carry meaningful consequences for the athlete. Cardiopulmonary exercise testing (CPET) provides a dynamic, functional complement to structural and electrical assessment, but its value in this specific differential-diagnosis context has not been comprehensively synthesized. This narrative review examines current evidence on CPET in distinguishing athlete’s heart from hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic cardiomyopathy, and thoracic wall deformities such as pectus excavatum, alongside the physiological basis of high exercise capacity in athletes and the athlete-specific reference values now becoming available. Across conditions, peak oxygen uptake alone proved an unreliable discriminator. Ventilatory efficiency, oxygen-pulse kinetics, and the exercise arrhythmic and blood-pressure response appear to carry additional information when interpreted within a multiparametric framework, although the supporting studies are observational, mostly single-centre, and were not designed to compare these variables against one another. Special populations, including veteran athletes, women, and those with congenital heart disease, require dedicated reference data that remain incomplete, and emerging artificial-intelligence-based interpretive tools require athlete-specific validation before clinical adoption. A practical, stepwise diagnostic framework integrating CPET with imaging and shared decision-making is proposed. It reflects the authors’ synthesis of the reviewed evidence rather than a prospectively validated or society-endorsed pathway. Closing the evidence gaps identified here, particularly for underrepresented athlete populations and prospective outcomes data, should be a priority for future research in sports cardiology.
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Caloian et al. (2026) conducted a review in Athlete's heart and cardiac pathology. Cardiopulmonary exercise testing (CPET) was evaluated. Cardiopulmonary exercise testing provides complementary functional information to distinguish athlete's heart from cardiac pathology, though peak oxygen uptake alone is an unreliable discriminator.
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