Prevalence and significance of T-wave inversion in Arab and Black paediatric athletes: Should anterior T-wave inversion interpretation be governed by biological or chronological age?

Blood Test-Based Age Acceleration Is Inversely Associated with High-Volume Sports Activity

PURPOSE

We develop blood test-based aging clocks and examine how these clocks reflect high-volume sports activity.

METHODS

We use blood tests and body metrics data of 421 Hungarian athletes and 283 age-matched controls (mean age, 24.1 and 23.9 yr, respectively), the latter selected from a group of healthy Caucasians of the National Health and Nutrition Examination Survey (NHANES) to represent the general population ( n = 11,412). We train two age prediction models (i.e., aging clocks) using the NHANES dataset: the first model relies on blood test parameters only, whereas the second one additionally incorporates body measurements and sex.

RESULTS

We find lower age acceleration among athletes compared with the age-matched controls with a median value of -1.7 and 1.4 yr, P < 0.0001. BMI is positively associated with age acceleration among the age-matched controls ( r = 0.17, P < 0.01) and the unrestricted NHANES population ( r = 0.11, P < 0.001). We find no association between BMI and age acceleration within the athlete dataset. Instead, age acceleration is positively associated with body fat percentage ( r = 0.21, P < 0.05) and negatively associated with skeletal muscle mass (Pearson r = -0.18, P < 0.05) among athletes. The most important blood test features in age predictions were serum ferritin, mean cell volume, blood urea nitrogen, and albumin levels.

CONCLUSIONS

We develop and apply blood test-based aging clocks to adult athletes and healthy controls. The data suggest that high-volume sports activity is associated with slowed biological aging. Here, we propose an alternative, promising application of routine blood tests.

The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions

Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.

Cardiomyopathies in children: An overview

Paediatric cardiomyopathies form a heterogeneous group of disorders characterized by structural and electrical abnormalities of the heart muscle, commonly due to a gene variant of the myocardial cell structure. Mostly inherited as a dominant or occasionally recessive trait, they might be part of a syndromic disorder of underlying metabolic or neuromuscular defects or combine early developing extracardiac abnormalities (i.e., Naxos disease). The annual incidence of 1 per 100,000 children appears higher during the first two years of life. Dilated and hypertrophic cardiomyopathy phenotypes share an incidence of 60% and 25%, respectively. Arrhythmogenic right ventricular cardiomyopathy (ARVC), restrictive cardiomyopathy, and left ventricular noncompaction are less commonly diagnosed. Adverse events such as severe heart failure, heart transplantation, or death usually appear early after the initial presentation. In ARVC patients, high-intensity aerobic exercise has been associated with worse clinical outcomes and increased penetrance in at-risk genotype-positive relatives. Acute myocarditis in children has an incidence of 1.4-2.1 cases/per 100,000 children per year, with a 6-14% mortality rate during the acute phase. A genetic defect is considered responsible for the progression to dilated cardiomyopathy phenotype. Similarly, a dilated or arrhythmogenic cardiomyopathy phenotype might emerge with an episode of acute myocarditis in childhood or adolescence. This review provides an overview of childhood cardiomyopathies focusing on clinical presentation, outcome, and pathology.

Protecting the stars of tomorrow: do international cardiovascular preparticipation screening policies account for the paediatric athlete? A systematic review and quality appraisal

OBJECTIVE

(1) Identify and review current policies for the cardiovascular screening of athletes to assess their applicability to the paediatric population and (2) evaluate the quality of these policy documents using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool.

DESIGN

Systematic review and quality appraisal of policy documents.

DATA SOURCES

A systematic search of PubMed, MEDLINE, Scopus, Web of Science, SportDiscus and CINAHL.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

An article was included if it was a policy/position statement/guideline/consensus or recommendation paper relating to athletes and cardiovascular preparticipation screening.

RESULTS AND SUMMARY

Of the 1630 articles screened, 13 met the inclusion criteria. Relevance to paediatric athletes was found to be high in 3 (23%), moderate in 6 (46%) and low in 4 (31%), and only 2 provide tailored guidance for the athlete aged 12-18 years. A median 5 related citations per policy investigated solely paediatric athletes, with study designs most commonly being retrospective (72%). AGREEII overall quality scores ranged from 25% to 92%, with a median of 75%. The lowest scoring domains were rigour of development; (median 32%) stakeholder involvement (median 47%) and Applicability (median 52%).

CONCLUSION

Cardiac screening policies for athletes predominantly focus on adults, with few providing specific recommendations for paediatric athletes. The overall quality of the policies was moderate, with more recent documents scoring higher. Future research is needed in paediatric athletes to inform and develop cardiac screening guidelines, to improve the cardiac care of youth athletes.

The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions

Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.

The juvenile ECG pattern in adolescent athletes and non-athletes in a national cardiac screening program (BEAT-IT)

BACKGROUND

Anterior T wave inversion (TWI) is frequent in healthy adolescent individuals (juvenile ECG pattern), normalising after puberty. Its clinical implications are uncertain.

AIM

This study assessed a) national prevalence of anterior TWI, b) ST segment morphology, c) proportion of individuals with a juvenile ECG pattern whose ECG normalises and d) factors predicting TWI persistence >16 years.

METHODS

Adolescents (mean 15y) in Malta were systematically invited to enrol in a cardiac screening program. Subjects completed a health questionnaire and an ECG at their school. Participants with TWI were labelled as TWI in V₁-V₂ or extended TWI (V₁-V₃/₄). The latter were followed at 1 year with a repeat ECG. Those with persistent extended anterior TWI were offered evaluation and surveillance.

RESULTS

The prevalence of isolated anterior TWI was 5.0%, commoner in females (6.3%) independent of athletic ability. Extended TWI was commoner in female athletes (4.2%, non-athletes 2.1%). Females often had shallow TWI without overt ST segment abnormalities. Deep TWI and ST segment changes were more frequent in males. Only 0.2% of cases persisted ≥16 years of age. ST segment characteristics were not able to predict T wave normalisation. No events took place during follow up (40 ± 9 months).

CONCLUSION

Anterior TWI is a frequent phenomenon in adolescents, especially in females. Female athletes are also more likely to have extended anterior TWI. Only 0.2% of cases have persistent anterior TWI at 16 years of age. Chest wall anatomy may explain this phenomenon in females. It is uncommon in males, hence why surveillance is more prudent.

Accuracy of the "International Criteria" for ECG screening in athletes in comparison with previous published criteria: rationale and design of a diagnostic meta-analysis

INTRODUCTION

The impact of the International Criteria for ECG interpretation in athletes has further improved the diagnostic accuracy of the 12-lead ECG use for preparticipation screening (PPS); moreover, these criteria have been evaluated in different populations of athletes and settings proving good results.

EVIDENCE ACQUISITION

We aimed to perform a comprehensive review of the use of the International Criteria for ECG interpretation in athletes, stemming from a systematic review to diagnostic meta-analysis, limiting our inclusion only to observational studies to determine the diagnostic accuracy of ECG for detecting cardiac anomalies related to sudden cardiac death in athletes.

EVIDENCE SYNTHESIS

This meta-analysis is expected to include several important studies related to PPS on different populations of athletes comparing different ECG criteria and detail important data on the diagnostic accuracy of ECG in PPS. Furthermore, we intend to highlight the advantage of using ECG in PPS.

CONCLUSIONS

The present diagnostic meta-analysis results will aid sports medicine physicians and cardiologist in adhering to the most accurate criteria for ECG evaluation in athletes and it may help to solve controversies aroused regarding the excess cost of ECG in PPS related to the amount of false positive cases.

The Impact of Ethnicity on Athlete ECG Interpretation: A Systematic Review

Athlete ECG interpretation criteria have been developed and refined from research in athlete populations; however, current guidelines are based on available data primarily from Caucasian and Black athletes. This study aimed to assess the impact of ethnicity on ECG interpretation in athletes. A systematic review was conducted of the MEDLINE, EMBASE, Scopus, SPORTDiscus, and Web of Science databases, for papers that assessed athlete screening ECGs and compared findings on the basis of ethnicity. Fifty-one papers which compared ECGs from various ethnicities were included. Most studies assessed Black athletes against Caucasian athletes and found a greater prevalence of T-wave inversion (TWI) (2.6–22.8% vs. 0–5.0%) and anterior TWI (3.7–14.3% vs. 0.6–2.0%). Black athlete subgroups in Africa had TWI (20–40%) and anterior TWI (4.3–18.7%) at a higher prevalence than other Black athletes. Athletes who were defined as mixed-race, Asian, and Pacific Islander are potentially more like Black athletes than Caucasian athletes. Black ethnicity is known to have an impact on the accurate interpretation of athlete ECGs; however, there is nuance related to origin of both parents. Asian and Pacific Islander origin also may impact athlete ECG interpretation. Further research is required to assist in distinguishing abnormal and normal athlete ECGs in different ethnic populations.

Association of T-wave abnormalities with major cardiovascular events in diabetes: the ACCORD trial

AIMS/HYPOTHESIS

T-wave abnormalities (TWA) are often found on ECG and signify abnormal ventricular repolarisation. While TWA have been shown to be associated with subclinical atherosclerosis, the relationship between TWA and hard cardiovascular endpoints is less clear and may differ in the presence of diabetes, so we sought to explore these associations in participants from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.

METHODS

TWA were operationally defined as the presence of any Minnesota Codes 5-1 through 5-4 in any lead distribution. Multivariable Cox proportional hazards models were constructed to examine relationships between TWA and clinical cardiovascular events. Secondary analyses explored the risks conferred by major vs minor TWA, differential effects of TWA by anatomic localisation (anterolateral, inferior or anterior lead distributions), and differing associations in those with or without prevalent CVD.

RESULTS

Among 8176 eligible participants (mean 62.1 ± 6.3 SD years, 61.4% male), there were 3759 cardiovascular events, including 1430 deaths (473 of a cardiovascular aetiology), 474 heart failure events, 1452 major CHD events and 403 strokes. Participants with TWA had increased risks of all-cause mortality (HR 1.45 [95% CI 1.30, 1.62], p < 0.0001), cardiovascular mortality (HR 1.93 [1.59, 2.34], p = 0.0001), congestive heart failure (HR 2.04 [1.69, 2.48], p < 0.0001) and major CHD (HR 1.40 [1.26, 1.57], p < 0.0001), but no increased risk of stroke (HR 0.99 [0.80, 1.23], p = 0.95). Major TWA conferred a higher risk than minor TWA. When TWA were added to the UK Prospective Diabetes Study risk engine, there was improved discrimination for incident CHD events, but only for those with prevalent CVD (area under the receiver operating characteristic curve 0.5744 and 0.6030 with p = 0.0067). Adding TWA to the risk engine yielded improvements in reclassification that were of greater magnitude in those with prevalent CVD (net reclassification improvement [NRI] 0.24 [95% CI 0.16, 0.32] in those with prevalent CVD, NRI 0.14 [95% CI 0.07, 0.22] in those without prevalent CVD).

CONCLUSIONS/INTERPRETATION

The presence and magnitude of TWA are associated with increased risk of clinical cardiovascular events and mortality in individuals with diabetes and may have value in refining risk, particularly in those with prevalent CVD. Graphical abstract.

The determinants of positivisation of anterior T-wave inversion in children

BACKGROUND

Anterior T-wave inversion (aTWI) can be a common electrical sign in cardiomyopathies but also a benign feature regressing with age in healthy children. Unfortunately, little is known about the age of positivisation of aTWI and its determinants in children and longitudinal data are not available. The aim of this longitudinal study was to identify the age and determinants of positivisation of aTWI in healthy children.

METHODS

ATWI was observed in 331 healthy children. They were evaluated yearly until positivisation for a maximum period of 4 years. Positivisation of aTWI was observed in 312 children (94%). The weight, height/length and their respective percentiles at birth and at the time of positivisation of aTWI and weeks of gestation at birth were collected.

RESULTS

Positivisation of aTWI occurred at a mean age of 13.0±2.0 years. When aTWI became positive, the majority of children had a height between 51° and 75° or over the 75° percentile. At the multivariate logistic regression analysis height, weight, percentiles of height and weight at the time of positivisation were identified as the strongest independent predictors of the positivisation of aTWI. No correlation was found for prematurity and anthropometrics characteristics at birth.

CONCLUSIONS

ATWI is a common feature of pediatric ECG, usually regressing with age. Height, weight, percentiles of height and weight at the time of positivisation were identified as determinants of TWI positivisation. These simple anthropometric characteristics should be used in addition to chronological age in order to interpret aTWI in children.

Electrocardiographic interpretation in athletes

Participation in regular exercise of moderate intensity is associated with a plethora of systemic benefits, including a reduction in risk factors for coronary atherosclerosis; however, intensive exercise may paradoxically culminate in sudden cardiac arrest among individuals harboring arrhythmogenic substrates. The precise mechanism for arrhythmogenesis is likely multifactorial, however, surges in catecholamines, electrolyte shifts, acid-base disturbances, increased core temperature and demand myocardial ischemia are potential contributors. Although most deaths occur in middle aged and older males with atherosclerotic coronary artery disease, a significant proportion also affect young athletes with inherited or congenital cardiac abnormalities. The impact of such catastrophes on society, particularly when a young high-profile athlete is affected could be considered a justified reason for identifying individuals who may be at risk. Given the rarity of deaths in young athletes, only the simplest screening test, such as the 12-lead electrocardiography (ECG) may be considered to be cost effective. The ECG is effective for detecting serious electrical diseases in young athletes such as congenital electrical accessory pathways and ion channel diseases but can also identify athletes with potential life-threatening structural diseases such as hypertrophic and arrhythmogenic cardiomyopathy. One of the concerns about ECG screening is that regular intensive exercise results in several physiological alterations in cardiac structure and function that are reflected on the athlete's ECG. Sinus bradycardia, first-degree atrioventricular block, incomplete right bundle branch block, minor J-point elevation and large QRS voltages are common. Conversely, some repolarization anomalies affecting the ST segment, T waves and QT interval may overlap with patterns observed in patients with serious cardiac diseases. The situation is complicated further because age, sex and ethnicity of the athletes also influence the ECG and there is a risk that erroneous interpretation could have serious consequences. This review will describe the normal electrical patterns of the "athlete's heart" and provide insights into differentiation physiological electrical patterns from those observed in serious cardiac disease.

The Impact of Ethnicity on Cardiac Adaptation

Regular intensive exercise is associated with a plethora of electrical, structural and functional adaptations within the heart to promote a prolonged and sustained increase in cardiac output. Bradycardia, increased cardiac dimensions, enhanced ventricular filling, augmentation of stroke volume and high peak oxygen consumption are recognised features of the athlete's heart. The type and magnitude of these adaptations to physical exercise are governed by age, sex, ethnicity, sporting discipline and intensity of sport. Some athletes, particularly those of African or Afro-Caribbean (black) origin reveal changes that overlap with diseases implicated in sudden cardiac death. In such instances, erroneous interpretation has potentially serious consequences ranging from unfair disqualification to false reassurance. This article focuses on ethnic variation in the physiological cardiac adaption to exercise.

Criteria for interpretation of the athlete's ECG: A critical appraisal

The electrocardiogram (ECG) is cheap and widely available but its use as a screening tool for early identification of athletes with a cardiac disease at risk of sudden cardiac death is controversial because of presumed low specificity. In the last decade, several efforts have been made to improve the distinction between physiological and pathological ECG findings in the athlete, leading to continuous evolution of the interpretation criteria. The most recent 2017 International criteria grouped ECG changes into three categories: normal, borderline, and abnormal. Borderline findings warrant further investigations only when two or more are present while abnormal changes should always be considered as the sign of a possible underlying disease. This review encompasses the evolution of the athlete's ECG interpretation criteria and highlights areas of uncertainty that will need to be addressed by further studies.

Young athletes' ECG: Incomplete right bundle branch block vs crista supraventricularis pattern

BACKGROUND

Incomplete right bundle branch block (IRBBB) is prevalent among athletes, but its etiology remains to be clearly elucidated and the commonly advocated mechanism, an intraventricular conduction delay, does not explain all cases. In the general population, an apparently similar phenomenon but with different pathophysiology and potential consequences, "crista supraventricularis pattern" (CSP, defined as QRS ≤ 100 ms, S wave <40 ms in I or V6 together with an RSR´ pattern in lead-V1) has been described. Yet, this manifestation has not been studied in athletes. Given that IRBBB can be associated with some serious conditions (including Brugada syndrome, arrhythmogenic cardiomyopathy, or atrial septal defects) the differentiation between IRBB and CSP could enhance the accuracy of the pre-participation screening (PPS). We thus aimed to determine the prevalence of CSP in young athletes.

METHODS

Observational study of standard 12-lead resting ECG in a cohort of children (5-16 years) attending a PPS program (August 2018-May 2019).

RESULTS

6,401 children (mean ± SD age 11.2 ± 2.9 years, 99.2% Caucasian, 93.8% male, 97.2% soccer players) were studied. We found CSP in 850 participants (prevalence = 13.3% [95% confidence interval 12.5-14.1]) whereas 553 (8.6%) had IRBBB. The proportion of athletes showing an S1S2S3 pattern was higher in those with CSP compared with the other QRS morphologies (P < .05).

CONCLUSIONS

CSP might have been overlooked in previous reports of sports PPS for children and misdiagnosed as IRBBB, as the proportion of the former condition was higher. Our findings might add useful information to improve the interpretation of the young athletes' ECG and thus the diagnostic value of PPS.

The adolescent athlete's heart; A miniature adult or grown-up child?

The systematic development of early age talent in sports academies has led to the professionalization of pediatric sport and the sports physician need to be aware of pediatric cardiological problems. Research into the medical cardiac care and assessment of the pediatric athlete are accumulating, but specific pediatric international guidelines are not available yet and reference data for ECG and echocardiography are incomplete, in particular for the age group <12 years of age. This article is an introduction to the physiological and diagnostics specifics of the pediatric athlete. The focus lies in the differences in presentation and diagnosis between pediatric and adult athletes for the most common pathologies. Reference data for electrical and structural adaptations to intensive exercise are sparse particularly in athletes aged below 12 years old. Training related changes include decrease of resting heart rate, increase of cardiac output, ventricular cavity size, and wall thickness. Cardiac hypertrophy is less pronounced in pediatric athletes, as HR mediated cardiac output increase to endurance exercise is the dominant mechanism in peripubertal children. As in adults, the most pronounced cardiovascular adaptations appear in classical endurance sports like rowing, triathlon, and swimming, but the specifics of pediatric ECG and echocardiographic changes need to be considered.

The Assessment of the Paediatric Athlete

The success of systematic early age talent development has led to the professionalisation of youth sports academies used by clubs and governing bodies alike, and sports physicians are nowadays commonly confronted with paediatric cardiological problems. Medical cardiac care of the paediatric athlete is however in its infancy, and the international guidelines that are present for adult athletes, are not yet available. Similarly, reference data for ECG and echocardiography are incomplete. The aim of this article is to provide and introduction to the cardiac care of the paediatric athlete to facilitate healthy and above all, safe talent development, but also provide guidance on how to distinguish adaptive, beneficial cardiovascular remodelling from underlying pathology of congenital or inherited cardiovascular disease. Differences in presentation, diagnosis and treatment between childhood and adult athletes are highlighted and can educate the reader in the emerging field of paediatric sports cardiology.

Interpretation of T-wave inversion in physiological and pathological conditions: Current state and future perspectives

The presence of T‐wave inversion (TWI) at 12‐lead electrocardiogram (ECG) in competitive athletes is one of the major diagnostic challenges for sports physicians and consulting cardiologists. Indeed, while the presence of TWI may be associated with some benign conditions and it may be occasionally seen in healthy athletes presenting signs of cardiac remodeling, it may also represent an early sign of an underlying, concealed structural heart disease or life‐threatening arrhythmogenic cardiomyopathies, which may be responsible for exercise‐related sudden cardiac death (SCD). The interpretation of TWI in athletes is complex and the inherent implications for the clinical practice represent a conundrum for physicians. Accordingly, the detection of TWI should be viewed as a potential red flag on the ECG of young and apparently healthy athletes and warrants further investigations because it may represent the initial expression of cardiomyopathies that may not be evident until many years later and that may ultimately be associated with adverse outcomes. The aim of this review is, therefore, to report an update of the literature on TWI in athletes, with a specific focus on the interpretation and management.

ECG criteria for the detection of high-risk cardiovascular conditions in master athletes

Objective

Structured electrocardiography (ECG) analysis is used to screen athletes for high-risk cardiovascular conditions (HRCC) to prevent sudden cardiac death. ECG criteria have been specified and recommended for use in young athletes ≤ 35 years. However, it is unclear whether these ECG criteria can also be applied to master athletes >35 years.

Aim

The purpose of this study was to test whether the existing ECG criteria for detecting HRCC in young athletes can be applied to master athletes.

Methods

We conducted a cross-sectional study among athletes >35 years screened for HRCC between 2006 and 2010. We performed a blinded retrospective analysis of master athletes’ ECGs, separately applying European Society of Cardiology (ESC)-2005, Seattle, and International criteria. HRCC were defined using recommendations from the international cardiac societies American Heart Association and American College of Cardiology, and ESC, based on ECG screening and cardiovascular evaluation (CVE).

Results

We included 2578 master athletes in the study, of whom 494 had initial screening abnormalities mandating CVE. Atrial enlargement (109, 4.1%) and left ventricular hypertrophy (98, 3.8%) were the most common ECG abnormalities found using the ESC-2005 or Seattle criteria. Applying the International criteria, ST-segment deviation (66, 2.6%), and T-wave inversion (58, 2.2%) were most frequent. The ESC-2005 criteria detected more HRCC (46, 1.8%) compared with the Seattle (36, 1.4%) and International criteria (33, 1.3%). The most frequently detected HRCC was coronary artery disease (24, 0.9%).

Conclusion

ECG criteria recommended for use in young athletes can be applied to master athletes’ ECGs to detect HRCC. The ESC-2005 criteria had the highest sensitivity for detecting HRCC among master athletes.

Abnormal ECG Findings in Athletes: Clinical Evaluation and Considerations

PURPOSE OF REVIEW

Pre-participation cardiovascular evaluation with electrocardiography is normal practice for most sporting bodies. Awareness about sudden cardiac death in athletes and recognizing how screening can help identify vulnerable athletes have empowered different sporting disciplines to invest in the wellbeing of their athletes.

RECENT FINDINGS

Discerning physiological electrical alterations due to athletic training from those representing cardiac pathology may be challenging. The mode of investigation of affected athletes is dependent on the electrical anomaly and the disease(s) in question. This review will highlight specific pathological ECG patterns that warrant assessment and surveillance, together with an in-depth review of the recommended algorithm for evaluation.

The impact of sex, age and training on biventricular cardiac adaptation in healthy adult and adolescent athletes: Cardiac magnetic resonance imaging study

Aims

Physiological cardiac adaptation in athletes is influenced by multiple factors. This study aimed to investigate the impact of sex, age, body size, sports type and training volume on cardiac adaptation in healthy athletes with cardiac magnetic resonance imaging.

Methods

A total of 327 athletes (242 male) were studied (adults ≥18 years old; adolescents 14–18 years old). Left and right ventricular ejection fractions, end-diastolic volume, end-systolic volume, stroke volumes and masses were measured. Left ventricular end-diastolic volume/left ventricular mass, right ventricular end-diastolic volume/right ventricular mass and derived right/left ventricular ratios were determined to study balanced ventricular adaptation. Athletes were categorised as skill, power, mixed and endurance athletes.

Results

Male athletes had higher left and right ventricular volumes and masses in both adult ( n = 215 (145 male); 24 ± 5 years old) and adolescent ( n = 112 (97 male); 16 ± 1 years old) groups compared with women (all P < 0.05). In adults, male sex, age, body surface area, weekly training hours, mixed and endurance sports correlated with higher ventricular volumes and masses (all P < 0.05); and a combination of age, sex, training hours, endurance and mixed sports explained 30% of the variance of the left ventricular end-diastolic volume index ( r = 0.30), right ventricular end-diastolic volume index ( r = 0.34), right ventricular mass index ( r = 0.30); and as much as 53% of the left ventricular mass index ( r = 0.53) (all P < 0.0001). In adolescents, positive correlations were found between training hours and left ventricular hypertrophy ( r = 0.39, P < 0.0001), and biventricular dilation (left ventricular end-diastolic volume r = 0.34, P = 0.0008; right ventricular end-diastolic volume r = 0.36, P = 0.0004). In adolescents, age and body surface area did not correlate with cardiac magnetic resonance parameters.

Conclusion

There are significant sex differences in the physiological adaptation of adult and adolescent athlete’s heart; and male sex, higher training volume and endurance sports are major determinants of sports adaptation in adults.