Cardiac Assessment of the Elite Athlete: Separating Structural Disease from Adaptive Changes

Sudden cardiac death is the number one cause of medical mortality in elite athletes and thus the cardiac assessment of this group is of paramount importance. Key to this evaluation is distinguishing structural heart disease, such as cardiomyopathy or thoracic aortic disease, from the normal physiologic changes of athlete’s heart. While most athletes will have aortic and LV size, LV function, and LV mass in the normal range, there are those who will have measurements in a grey zone which will require a more comprehensive approach. Here we discuss how a detailed personal and family history, ECG, ambulatory ECG monitoring, and multi-modality imaging with resting and stress echocardiography, cardiopulmonary exercise testing and cardiac MRI can be employed to make a correct diagnosis. In addition, we discuss how risk stratification and shared decision making with athletes can be employed to guide decisions about continued participation in sports at the elite competitive level.