Search Results (123)

Late gadolinium enhancement (LGE) cardiac magnetic resonance is the reference standard for non-invasive myocardial tissue characterization. Conventional LGE analysis focuses on the presence and extent of fibrosis, yet these measures incompletely describe the spatial complexity of myocardial scar that underpins arrhythmogenesis. Entropy, derived from radiomic analysis of LGE signal-intensity distributions, has emerged as a surrogate marker of myocardial tissue heterogeneity. Mechanistically, heterogeneous fibrosis promotes electrical conduction alterations, and entropy serves as a global descriptor of this complex substrate. A growing body of evidence suggests that higher LGE entropy is associated with increased arrhythmogenicity and major adverse cardiac events. Several studies have shown that this association remains significant after adjustment for conventional clinical and imaging predictors. A smaller number of studies have gone further, demonstrating that incorporation of LGE entropy improves the discriminatory or reclassification performance of established risk-prediction models. This narrative review critically synthesizes the current evidence on LGE-derived entropy, compares methodological approaches and clinical applications, and discusses its principal limitations. After standardization and prospective validation, entropy-based phenotyping may prove useful for individualized risk stratification beyond conventional LGE metrics and guide clinical decision-making. Full article

Myocardial bridging (MB) is a congenital coronary anomaly in which a segment of an epicardial coronary artery courses intramurally beneath the myocardium for part of its length, resulting in dynamic compression during systole. Once considered a largely benign incidental finding, accumulating evidence has demonstrated MB to be a clinically significant substrate for myocardial ischemia, arrhythmia, and sudden cardiac death (SCD), particularly under conditions of elevated adrenergic drive such as vigorous physical exercise. The prevalence of MB is highly dependent on the diagnostic modality used, ranging from approximately 0.5–2.5% on coronary angiography to 15–85% on post-mortem and advanced intravascular imaging studies, reflecting a substantial detection gap- in particular on routine cardiac screening tests. This review critically examines the current evidence base regarding MB in the context of competitive and recreational sport. We address: (1) the pathophysiology of exercise-induced hemodynamic compromise in MB; (2) the limitations of existing screening modalities—including electrocardiography, echocardiography, exercise stress testing, and advanced coronary imaging in identifying athletes at risk; (3) the clinical management of symptomatic MB, encompassing pharmacological therapy, coronary revascularization strategies, and catheter-based interventions; and (4) physical activity guidance for athletes with known or suspected MB. Full article

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. Full article

Physical activity wields a positive influence on atherosclerosis-related risk factors; however, the effects of high-intensity training on cardiovascular (CV) health are not unequivocal. The prevalence of coronary artery disease (CAD) in middle-aged sportsmen varies from 13.7% to 71%. Despite increased longevity and lower overall CV risk, CAD remains a serious problem in athletes, being responsible for the majority of sudden cardiac death (SCD) cases in sportsmen over 30 years. Endurance athletes engaging in high-intensity training are burdened with increased coronary artery calcification (CAC) of multifactorial pathophysiology, embracing i.a. wall shear stress, excessive reactive oxygen species, inflammatory mediators and increased levels of parathyroid hormone. Thanks to improved coronary vasodilatory capacity and coronary collateralization, sportsmen are rarely affected by hemodynamically significant coronary artery stenosis, and the atherosclerotic plaques are mostly of benign, calcified morphology. The basic screening should embrace medical history, CV risk assessment and rest electrocardiogram (ECG). Stress ECG tests, computed tomography (CT) with or without contrast, and functional imaging tests are additional diagnostic options. Because CAD in athletes remains a subject of research, the article aims at bringing closer the up-to-date findings on this matter, with a summary of diagnostic tools and clinical implications. Full article

The “athlete’s heart” represents a physiological condition consequent to long-term adaptation to sport-specific training loads. Cardiac imaging is a pivotal tool in the assessment of athletes. The study of the autonomic nervous system (ANS) using heart rate variability is becoming increasingly popular in sports fields, given its fundamental role in cardiovascular adaptation to exercise. Unfortunately, many barriers limit the clinical use of this methodology. In this observational study of 330 elite athletes, we used a composite index of ANS control (ANSI), designed to overcome pitfalls, following the hypothesis that studying the ANS could help address cardiac adaptation to high-volume training. In athletes subdivided into three groups considering the level (LOW/HIGH) of combined static/dynamic exercise and the presence [+]/absence [−] of left ventricular hypertrophy (LVH), we found that ANSI showed a progressive increase (LOW: 38.2 ± 27.6%; HIGH-LVH [−]: 52.1 ± 27.2%; HIGH-LVH [+]: 64.4 ± 24.9%, J-T test p < 0.001), with significant differences between all groups considered (p < 0.001). After adjustment and within the HIGH group, ANSI showed the strongest association with LVH and the highest explanatory power among autonomic variables. In conclusion, ANSI was able to differentiate elite athletes characterized by different cardiac remodeling and workloads (as suggested by different sport disciplines), corroborating the hypothesis for a wider use of ANS evaluation in the sports field. Full article

Objectives: We aimed to systematically review and meta-analyze the impact of COVID-19 infection on cardiorespiratory fitness (CRF): (1) within-athlete (the same participants before and after infection), and (2) between-athlete (infected vs. healthy reference participants). Methods: In this systematic review (PROSPERO Registry: CRD42024540430) we included observational studies enrolling recreational or competitive athletes ≥18 years old with laboratory confirmation of SARS-CoV-2 infection. The primary outcome was change in relative maximal oxygen uptake (VO_2max). Secondary outcomes included changes in absolute VO_2max, maximal ventilation (VE_max), and maximal heart rate (HR_max). We searched Embase, PubMed, Medline, Scopus, and Web of Science up to August 9th, 2025. Risk of bias was assessed with the JBI critical appraisal tool. Meta-analyses were performed with a random-effects model. Results: Twelve studies enrolling a total of 1595 participants met the eligibility criteria. COVID-19 infection was associated with lower relative VO_2max (MD = −1.83 mL·kg⁻¹·min⁻¹; 95%CI [−3.16, −0.49]; p = 0.007; I² = 54%) and absolute VO_2max (MD = −0.15 L·min⁻¹; 95%CI [−0.29, −0.01]; p = 0.03; I² = 0%). COVID-19 infection was associated with lower VE_max (MD = −7.99 L·min⁻¹; 95%CI [−12.94, −3.04]; p = 0.002; I² = 0%) but not with HR_max (MD = −0.34 bpm; 95%CI [−1.54, 0.86]; p = 0.58; I² = 0%). High heterogeneity of included studies was addressed with subgroup analyses. The risk of bias in most studies was high. The certainty of evidence was very low for each outcome. Conclusions: COVID-19 infection in athletes was associated with reduced VO_2max and VE_max. The relationships were highly dependent on the quality of the studies. CRF and athlete profile should be considered when making shared decisions regarding safe return to sport after infection. Full article

Cancer therapies have significantly improved survival but are frequently limited by cancer therapy-related cardiovascular toxicity (CTR-CVT). Cardiovascular imaging plays a central role in baseline risk stratification, surveillance during therapy and long-term follow-up. Transthoracic echocardiography (TTE) remains the first-line imaging modality; however, conventional parameters such as left ventricular ejection fraction (LVEF) often fail to detect early myocardial injury. Myocardial deformation imaging, particularly global longitudinal strain (GLS), has emerged as a sensitive marker of subclinical dysfunction across multiple cardiotoxic phenotypes. Cardiac magnetic resonance (CMR) further enhances diagnostic accuracy through tissue characterization techniques, enabling the detection of myocardial edema, inflammation, and fibrosis before overt functional decline. Different anticancer therapies induce distinct pathophysiological mechanisms of injury, each associated with characteristic imaging patterns. Emerging imaging biomarkers and multimodality approaches may improve early detection, the spatial characterization of myocardial injury and individualized surveillance strategies. Pediatric patients represent a uniquely vulnerable population due to their myocardial immaturity, altered pharmacokinetics and prolonged post-treatment life expectancy, resulting in a higher cumulative lifetime cardiovascular risk. In conclusion, a mechanism-based multimodality imaging approach integrating echocardiography, CMR and emerging data-driven technologies is essential to optimize early detection, risk stratification and long-term cardiovascular outcomes in both adult and pediatric cardio-oncology populations. Full article

Post-exercise release of cardiac biomarkers reflects physiological adaptations of the myocardium to exercise; however, data on their kinetics after exhaustive exercise under hypoxia remain scarce. We determined the kinetics of cardiac biomarker changes following a single bout of exercise to volitional exhaustion under normoxia and moderate normobaric hypoxia (2000 m and 3000 m a.s.l.) in trained (n = 12; VO_2max 64.2 ± 2.9 mL·kg⁻¹·min⁻¹) and untrained (n = 12; VO_2max 44.1 ± 7.4 mL·kg⁻¹·min⁻¹) men. Participants performed a graded exercise test (GXT) followed by a constant-workload exercise test (CXT) at the lactate threshold under three conditions (FiO₂ = 20.9%, 16.5%, 14.4%). Venous blood was sampled at rest, immediately post-exercise, and at 2, 6, and 24 h of recovery for determination of cardiac troponin T (cTnT) and I (cTnI), myoglobin (Mb), creatine kinase MB isoform (CK-MB), heart-type fatty acid-binding protein (H-FABP), ischemia-modified albumin (IMA), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) by ELISA. Exhaustive exercise induced significant elevations in all biomarkers, peaking at 2–6 h post-exercise and largely returning to resting values by 24 h. Moderate normobaric hypoxia did not augment the cardiac biomarker response; rather, it attenuated the increases in Mb, NT-proBNP, and IMA, likely due to earlier peripheral fatigue and lower absolute mechanical work. The inhibitory effect of hypoxia on cTnI release was observed exclusively in trained men, suggesting an interaction between training-related cardiac adaptations and the hypoxic stimulus. These findings support the safety of high-intensity exercise at simulated altitudes of 2000–3000 m a.s.l. Full article

Background/Objectives: Athletes are characterized by distinct haemodynamic adaptations of the cardiovascular system, including descending aorta haemodynamics, that could influence the diagnosis of coarctation of the aorta. This study aims to evaluate the normal range for the maximum velocity of blood flow in the descending aorta (Vmax-AoDesc) and the predictors of Vmax-AoDesc in apparently healthy athletes without coarctation of the aorta. Methods: We examined 559 asymptomatic healthy athletes with an age of at least 12 years and a tricuspid aortic valve (420 males, age: 29 ± 14 years). We performed evaluations of athletic history, measurements of brachial systolic and diastolic blood pressure, cardiac and aorta ultrasonography and cardiopulmonary exercise testing. Forty athletes were reassessed after a median follow-up of 3.0 (IQR: 2.1) years. Results: The median Vmax-AoDesc was 1.29 (IQR: 0.28) m/s, with a maximum of 2.00 m/s. The Vmax-AoDesc could be independently predicted by age (β = −0.392, p < 0.001), ratio of systole/diastole (β = 0.095, p = 0.023), brachial systolic blood pressure (β = 0.251, p < 0.001), left ventricular stroke volume (β = 0.256, p < 0.001), ascending aorta diameter (β = −0.230, p < 0.001), aortic arch diameter (β = −0.111, p = 0.044) and descending aorta diameter (β = −0.103, p = 0.017). Age accounted for the greatest variability of Vmax-AoDesc (5.8%). Vmax-AoDesc correlated positively with h/week of endurance exercise training (rho = 0.182, p < 0.001) and oxygen uptake at second ventilatory threshold (rho = 0.299, p = 0.001). Vmax-AoDesc did not change significantly during follow-up (p = 0.438). The median change in Vmax-AoDesc was −0.05 (IQR: 0.18) m/s. However, when Vmax-AoDesc was adjusted for all the above-mentioned independent predictors of Vmax-AoDesc apart from age and systolic blood pressure, there was a reduction in adjusted Vmax-AoDesc during follow-up (p = 0.007), indicating a reduction in Vmax-AoDesc with aging. Conclusions: The upper limit of the normal range for Vmax-AoDesc was 2.00 m/s in athletes without coarctation of the aorta. Young age was the most important predictor for the measurement of high Vmax-AoDesc. There was an upregulation of Vmax-AoDesc in athletes with a greater volume of endurance exercise training. Full article

Cardiopulmonary exercise testing (CPET) is the reference method for the objective assessment of exercise capacity because it provides an integrated appraisal of cardiovascular, respiratory and metabolic responses to exertion. However, CPET alone quantifies the magnitude of functional impairment without fully resolving the central and peripheral mechanisms that determine exercise intolerance. The integration of CPET with exercise stress echocardiography and near-infrared spectroscopy (NIRS) has therefore emerged as a clinically relevant multimodal strategy. Stress echocardiography provides real-time information on ventricular reserve, filling pressures, pulmonary pressure response, valvular function, pulmonary congestion and dynamic outflow obstruction, whereas NIRS provides continuous insight into skeletal muscle oxygen delivery, extraction and utilization. This narrative review summarizes the physiological rationale, practical workflow, methodological limitations and clinical applications of combined CPET, stress echocardiography and NIRS across heart failure, pulmonary hypertension, peripheral artery disease, cardiomyopathies and sports cardiology. By linking systemic gas exchange, central hemodynamics and peripheral oxygen handling, this approach may move exercise evaluation from a descriptive measure of performance toward a mechanism-based framework for phenotyping, risk stratification and individualized therapeutic decision-making. Further studies are needed to harmonize protocols, validate reproducible multimodal indices and demonstrate incremental prognostic value over conventional testing. Full article

Background: Artificial intelligence (AI) has shown promise in the interpretation of electrocardiograms (ECGs) using signal-based deep learning models. In parallel, large language models (LLMs) have gained increasing visibility in clinical practice, including exploratory applications in ECG analysis. Whether a general-purpose LLM can meaningfully discriminate cardiovascular disease from athlete ECGs during PPS remains unknown. We aimed to evaluate the diagnostic performance of a general-purpose LLM for this task. Methods: In this multicentre diagnostic accuracy study, we evaluated a commercially available LLM (ChatGPT, version 5) in 2950 competitive athletes undergoing PPS. All athletes underwent resting 12-lead ECG, with second- and third-line investigations performed when clinically indicated. The reference outcome was confirmed cardiovascular disease after full diagnostic work-up (n = 450, 15.3%). For each ECG, the LLM generated a numeric score (0–100) representing the inferred likelihood of underlying disease using a standardized prompt and without task-specific fine-tuning. Discriminative performance was assessed using receiver operating characteristic (ROC) analysis. Misclassification patterns were analysed according to International ECG Criteria. Results: GPT-derived scores demonstrated a marked floor effect, with a median value of 0 (IQR 0–2) in both diseased and non-diseased athletes and substantial overlap between groups. The area under the ROC curve was 0.52 (95% CI 0.49–0.55), indicating performance close to random classification. At the Youden-derived threshold, 79% of athletes with confirmed disease were incorrectly classified as negative. False-negative cases were predominantly characterized by borderline ECG patterns (82%), and a substantial number of red-flag ECG abnormalities were also missed. Conclusions: In this PPS cohort, a general-purpose LLM used in a naïve configuration showed no clinically meaningful ability to discriminate between cardiovascular disease and athlete ECGs. Without task-specific training or domain adaptation, such models should not be used for diagnostic triage in athlete screening. Full article

The growing participation in competitive and recreational sports has increased the clinical relevance of Sports Cardiology, particularly for athletes with borderline or ambiguous findings during cardiovascular screening. Advanced imaging is essential to differentiate physiological cardiac remodeling from early or subclinical cardiomyopathy. Cardiovascular magnetic resonance (CMR) has emerged as the reference standard for comprehensive assessment of cardiac morphology, function, and myocardial tissue characterization. Beyond conventional cine imaging and late gadolinium enhancement (LGE), parametric mapping techniques (including native T1, T2, and extracellular volume (ECV) quantification) enable quantitative and reproducible evaluation of diffuse fibrosis, edema, and low-grade inflammation that may precede overt structural disease. In athletes, physiological remodeling may overlap with pathologic phenotypes, posing diagnostic and prognostic challenges. Accurate interpretation requires integration of volumetric and functional measurements with the athlete’s training profile and electrocardiographic features, using population-specific reference values to avoid misclassification of adaptive changes as pathological. This narrative review provides a clinically oriented overview of CMR in athletes, focusing on typical findings, advanced tissue characterization, and emerging techniques such as myocardial strain analysis, right ventricular-focused imaging, and 4D flow. Technical challenges, standardization issues, and future directions are discussed. Multiparametric CMR is increasingly recognized as a key tool for improving diagnostic accuracy, refining risk stratification, and supporting clinical decision-making in athletes with suspected cardiomyopathy or ventricular arrhythmias. Full article

Ventricular repolarization abnormalities are among the most frequent electrocardiographic findings in pediatric athletes undergoing cardiovascular screening, yet their clinical significance remains a major source of diagnostic uncertainty. While most of them represent benign expressions of training-induced cardiac remodeling and developmental maturation, selected patterns may constitute the earliest phenotypic manifestation of cardiomyopathies or primary electrical disease. Distinguishing physiological adaptation from early pathology is therefore essential to prevent both sudden cardiac events and unnecessary restrictions on sports participation. This review integrates contemporary international electrocardiographic interpretation criteria with emerging pediatric evidence to provide a clinically oriented framework for evaluation and risk stratification of ventricular repolarization abnormalities in pediatric athletes. Early repolarization and anterior T-wave inversion are commonly benign when occurring within recognized age- and ethnicity-specific patterns and in the absence of symptoms, concerning family history, or structural abnormalities. Conversely, lateral or inferolateral T-wave inversion, atypical ST-segment morphology, complex ventricular arrhythmias, and abnormal imaging findings represent red flags requiring comprehensive investigation, including multimodality imaging when indicated. Due to the dynamic electrophysiological evolution during adolescence, longitudinal reassessment is crucial. A structured, risk-based approach integrating electrocardiographic features, demographic/familial context, clinical evaluation, imaging findings, and follow-up provides a pragmatic strategy to optimize risk detection while safeguarding appropriate athletic participation in young athletes. Full article