Circulation. 2000;101:336-344
(Circulation. 2000;101:336.)
© 2000 American Heart Association, Inc.
The Athletes Heart
A Meta-Analysis of Cardiac Structure and Function
Babette M. Pluim, MD;
Aeilko H. Zwinderman, PhD;
Arnoud van der Laarse, PhD;
Ernst E. van der Wall, MD, PhD
From the Interuniversity Cardiology Institute of the Netherlands,
Utrecht, the Netherlands (B.M.P., A.v.d.L., E.E.v.d.W.), and Departments of
Cardiology (B.M.P., A.v.d.L.; E.E.v.d.W.) and Medical Statistics (A.H.Z.),
Leiden University Medical Center, Leiden, the Netherlands.
Correspondence to Ernst E. van der Wall, MD, Department of Cardiology, Building 1, C5-P28, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands. E-mail vanderwall{at}cardio.azl.nl
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Abstract
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BackgroundIt has been
postulated that depending on the
type of exercise performed, 2
different morphological forms
of athletes heart may be distinguished:
a strength-trained
heart and an endurance-trained heart. Individual
studies have
not tested this hypothesis satisfactorily.
Methods and ResultsThe hypothesis of divergent cardiac
adaptations in endurance-trained and strength-trained athletes was
tested by applying meta-analytical techniques with the assumption of a
random study effects model incorporating all published
echocardiographic data on structure and function of
male athletes engaged in purely dynamic (running) or static (weight
lifting, power lifting, bodybuilding, throwing, wrestling) sports and
combined dynamic and static sports (cycling and rowing). The
analysis encompassed 59 studies and 1451 athletes. The overall
mean relative left ventricular wall thickness of control
subjects (0.36 mm) was significantly smaller than that of
endurance-trained athletes (0.39 mm, P=0.001),
combined endurance- and strength-trained athletes (0.40 mm,
P=0.001), or strength-trained athletes (0.44 mm,
P<0.001). There was a significant difference between
the 3 groups of athletes and control subjects with respect to left
ventricular internal diameter (P<0.001),
posterior wall thickness (P<0.001), and
interventricular septum thickness
(P<0.001). In addition, endurance-trained athletes and
strength-trained athletes differed significantly with respect to mean
relative wall thickness (0.39 versus 0.44, P=0.006) and
interventricular septum thickness (10.5 versus 11.8
mm, P=0.005) and showed a trend toward a difference with
respect to posterior wall thickness (10.3 versus 11.0 mm,
P=0.078) and left ventricular internal
diameter (53.7 versus 52.1 mm, P=0.055). With
respect to cardiac function, there were no significant differences
between athletes and control subjects in left ventricular
ejection fraction, fractional shortening, and E/A ratio.
ConclusionsResults of this meta-analysis regarding
athletes heart confirm the hypothesis of divergent cardiac
adaptations in dynamic and static sports. Overall, athletes heart
demonstrated normal systolic and diastolic cardiac
functions.
Key Words: exercise hypertrophy echocardiography myocardium
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Introduction
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Top-level training is often associated with morphological
changes
in the heart, including increases in left
ventricular chamber
size, wall thickness, and mass. The
increase in left ventricular
mass as a result of training
is called "athletes heart."
1 Morganroth et
al
2 were the first to postulate that 2 different
morphological
forms of athletes heart can be distinguished: a
strength-trained
heart and an endurance-trained heart. According to
their theory,
athletes involved in sports with a high dynamic component
(eg,
running) develop predominantly increased left
ventricular chamber
size with a proportional increase in
wall thickness caused by
volume overload associated with the high
cardiac output of endurance
training. Thus, endurance-trained athletes
are presumed to demonstrate
eccentric left ventricular
hypertrophy, characterized by an
unchanged relationship
between left ventricular wall thickness
and left
ventricular radius (ie, ratio of wall thickness to
radius).
Athletes involved in mainly static or isometric exercise
(eg,
weightlifting) develop predominantly increased left
ventricular
wall thickness with unchanged left
ventricular chamber size,
which is caused by pressure
overload accompanying the high systemic
arterial pressure
found in this type of exercise. Thus, strength-trained
athletes are
presumed to demonstrate concentric left ventricular
hypertrophy,
which is characterized by an increased ratio
of wall thickness
to radius.
Even though the morphology of athletes heart and the impact of
different sports on cardiac structure have been investigated recently
by several authors,3 4 5 6 they have not been able to resolve
satisfactorily the question regarding the existence of 2 types of
athletes heart. We chose to focus on the basic forms of exercise, ie,
dynamic exercise (long-distance running), static exercise (all sports
involving the throwing and lifting of heavy objects), and combined
dynamic and static exercise (cycling and rowing). The hypothesis of
divergent cardiac adaptations in endurance- and strength-trained
athletes was tested by applying meta-analytical techniques with the
assumption of a random study effects model of published data of male
athletes engaged in the sports mentioned above. Female athletes were
excluded, because to the best of our knowledge no studies on the effect
of strength training on the heart of female athletes are available.
Cardiac systolic and diastolic functions were also
studied to evaluate the relationship between geometry and function of
athletes heart.
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Methods
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Cardiac Structure
All available echocardiographic studies
from the medical literature
(from 1975 through 1998) on the anatomic
structure of the heart
in endurance-trained athletes (long-distance
runners), strength-trained
athletes (weight lifters, power lifters,
bodybuilders, wrestlers,
throwers), and athletes involved in combined
forms of dynamic
and static training (cyclists and rowers) were
identified (Tables
1


, 2

, and 3

). The outcome of the studies did
not influence inclusion
or rejection of data, and the following preset
criteria for
accepting data in our meta-analysis were applied:
homogeneous
groups of adult male athletes between 18 and 40
years of age.
Nonuniform groups of athletes, women, mixed groups of men
and
women, children (<18 years) and veterans (>40 years) were
excluded.
Only original publications were considered; review papers
were
excluded. Original studies had to include assessment of left
ventricular
internal diameter and wall thickness. When left
ventricular
mass was not reported, it was calculated with
the Penn-cube
formula
7 :
LVM=1.04[(LVIDd+PWTd+IVSTd)
3-LVIDd]-13.6 g,
in which
LVM indicates left ventricular mass; LVIDd, left
ventricular
end-diastolic internal diameter;
PWTd, diastolic posterior wall
thickness; and IVSTd,
diastolic interventricular septum thickness.
Relative
left ventricular wall thickness was calculated as
(PWTd+IVSTd)/LVIDd
and expressed as a fraction. When the
diastolic interventricular
septal thickness was
not reported, it was considered to be equal
to the
diastolic posterior wall thickness.
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Table 3. Subject Characteristics: Strength-Trained Athletes
(Weight Lifters, Power Lifters, Bodybuilders, Wrestlers, Throwers)
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Cardiac Function
All available echocardiographic studies from the
medical literature (from 1975 through 1998) on left
ventricular ejection fraction, fractional shortening, and
ratio of transmitral peak flow velocity during early left
ventricular filling and peak flow velocity during atrial
filling (E/A ratio) of endurance-trained athletes, strength-trained
athletes, and athletes receiving combined forms of dynamic and static
training were identified. The outcome of the studies did not influence
inclusion or rejection of data, and the same set of criteria for
accepting data as mentioned for cardiac structure assessment was
applied. To investigate whether there was any relationship between
cardiac geometry and left ventricular systolic and
diastolic functions, left ventricular function
was studied in the respective subgroups of endurance-trained athletes,
combined endurance- and strength-trained athletes, and strength-trained
athletes.
Statistical Analysis
The means of the posterior wall thickness,
interventricular septum thickness, left
ventricular internal diameter, ejection fraction,
fractional shortening, and E/A ratio in the individual studies were
analyzed by use of a meta-analysis model with a random
study effect as described by Dersimonian and Laird.8 The
different groups of athletes were also compared by use of this model. A
value of P
0.05 was considered statistically
significant.
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Results
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Cardiac Structure
In Table 4

, results of
echocardiographic data regarding cardiac
structure in
endurance-trained athletes, strength-trained athletes,
combined
endurance- and strength-trained athletes, and control
subjects are
summarized. There were 31 studies of endurance-trained
athletes,
2 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 23 studies of combined endurance-
and
strength-trained athletes,
16 19 24 26 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 and 24
studies of strength-trained
athletes*
included in the
meta-analysis. The analysis involved a total
of 413
endurance-trained athletes, 494 combined endurance- and
strength-trained
athletes, 544 strength-trained athletes, and 813
control subjects.
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Table 4. Cardiac Structure and Function in Endurance-Trained
Athletes, Combined Endurance and Strength-Trained Athletes,
Strength-Trained Athletes, and Control Subjects
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Mean Relative Wall Thickness
The overall mean relative left ventricular wall
thickness of control subjects (0.36 mm) was significantly smaller
than that of endurance-trained athletes (0.39 mm,
P=0.001), combined endurance- and strength-trained athletes
(0.40 mm, P=0.001), or strength-trained athletes
(0.44 mm, P<0.001). Also, the mean relative wall
thickness of endurance-trained athletes was significantly lower than
that of strength-trained athletes (0.39 versus 0.44 mm,
P=0.006). There was no significant difference in mean
relative wall thickness between endurance- and combined endurance- and
strength-trained athletes (P=0.04).
Left Ventricular Internal Diameter
There was a significant difference between the 3 groups of
athletes and control subjects with respect to left
ventricular internal diameter (P<0.001). The
endurance-trained athletes and strength-trained athletes showed a trend
toward a significant difference with respect to left
ventricular internal diameter (P=0.055).
Interventricular Septum Thickness
In 6 studies, interventricular septum thickness was
not mentioned and was considered to be equal to the posterior septum
thickness.11 15 17 22 27 51 There was a significant
difference with respect to interventricular septum
thickness between control subjects and endurance-trained athletes (8.8
versus 10.5 mm, P<0.001) and between endurance-trained
athletes and strength-trained athletes (10.5 versus 11.8 mm,
P=0.005) but not between endurance-trained athletes and
combined endurance-trained and strength-trained athletes
(P=0.042).
Posterior Wall Thickness
There was a significant difference in posterior wall thickness
between control subjects and endurance-trained athletes (8.8 versus
10.3 mm, P<0.001) but not between endurance-trained
athletes and combined endurance- and strength-trained athletes (10.3
versus 11.0 mm, P=0.064) or between endurance-trained
athletes and strength-trained athletes (10.3 versus 11.0 mm,
P=0.078).
Left Ventricular Mass
The overall mean left ventricular mass of the control
subjects (174 g) was significantly less than the overall mean left
ventricular mass of the endurance-trained athletes (249 g,
P<0.001), combined endurance- and
strength-trained athletes (288 g, P<0.001), or
strength-trained athletes (267 g, P<0.001).
Left ventricular mass did not differ significantly between
the 3 groups of athletes.
Cardiac Function
In Table 4
, results of echocardiographic
data from 50 studies on cardiac function in endurance-trained athletes,
strength-trained athletes, combined endurance- and strength-trained
athletes, and control subjects are summarized.
There were
no significant differences between the athletes and the control
subjects with respect to left ventricular ejection
fraction, fractional shortening, and E/A ratio.
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Discussion
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Cardiac Structure
The results of this meta-analysis of athletes heart
demonstrated
slightly divergent cardiac adaptations in dynamic and
static
sports, with an intermediate form of hypertrophy for
those sports
with combined high static and dynamic components. The
development
of an endurance-trained heart (eccentric
hypertrophy) and a
strength-trained heart (concentric
hypertrophy) is not to be
considered an absolute and
dichotomous concept. Endurance-trained
runners, who are thought to
develop pure eccentric left ventricular
hypertrophy,
demonstrated a more pronounced increase in
wall thickness than
expected, in addition to an increase in left
ventricular end-diastolic
diameter. This
resulted in an unexpected increase in relative
wall thickness. The
strength-trained weight lifters, power lifters,
bodybuilders, throwers,
and wrestlers, who are considered to
develop pure concentric left
ventricular hypertrophy, demonstrated
an
increase in both absolute and relative wall thickness and
a significant
increase in left ventricular diameter. Consequently,
the
geometric pattern of athletes heart is more complicated
than
expected. Endurance-trained athletes showed a significant
increase in
left ventricular relative wall thickness ratio instead
of a
proportional increase in left ventricular wall thickness
and
internal diameter with a normal relative wall thickness;
strength-trained
athletes showed an increase in left
ventricular diameter in
addition to an increase in left
ventricular wall thickness.
The combined endurance- and
strength-trained cyclists and rowers
showed a significant increase in
relative wall thickness and
the highest increase in left
ventricular internal diameter.
This observation is largely
in accordance with the results reported
by Spirito et al,
3
who performed the largest study on athletes
heart on 947 elite
athletes representing 27 different sports.
They ranked
sports according to the impact on left ventricular
diastolic
cavity dimension and left ventricular
wall thickness. Rowing
was ranked first according to the calculated
effect on left
ventricular wall thickness (with cycling
second), and cycling
was ranked first according to the calculated
effect on left
ventricular internal dimension (with rowing
seventh). The authors
convincingly demonstrated that sports differ
greatly with regard
to their impact on left ventricular
dimensions and that in general
athletes training in sports associated
with large diastolic
cavity dimensions also have relatively
high values of wall thickness.
Endurance-Trained Athletes
Adaptation of the heart to endurance training with an increase in
both diameter and wall thickness is useful if we take into account
heart rate and blood pressure responses during intense exercise. The
cardiac output of trained endurance athletes may increase from 5 to 6
L/min at rest to up to 40 L/min during maximal exercise.73
The heart adapts to this volume load with an increase in internal
diameter. Blood pressure also increases during endurance exercise,
although to a lesser extent than during strength training. Blood
pressure readings of 175/69 mm Hg during treadmill running were
recorded by Palatini et al.74 In other words, pure
volume load during endurance training does not exist; during
long-distance running, the heart has to adapt to both a volume and a
pressure load, whereby the endurance-trained heart shows an increase in
both left ventricular internal diameter and left
ventricular wall thickness.
Strength-Trained Athletes
Adaptation of the heart to strength training with a slight
increase in left ventricular internal diameter and a large
increase in left ventricular wall thickness can be
explained on the basis of blood pressure response and cardiac output
during weight lifting.75 76 77 78 During heavy-resistance
exercise, arterial blood pressure shows a large increase,
amounting to values to 480/350 mm Hg.75 However,
heart rate and cardiac output do not remain unchanged but show an
increase during strength training. MacDougall et al75
demonstrated that heart rate during weight lifting ranged from 102 bpm
between sets to peak values of 170 bpm during actual lifting.
Accordingly, pure pressure load during strength training does not
exist.
Combined Endurance- and Strength-Trained Athletes
Rowing and cycling represent typical strength and
endurance sports involving combined dynamic and static exercise of
large groups of muscles. Top-level cyclists can perform with a
near-maximal heart rate for long periods of time, sometimes up to 6
hours. Systolic and mean arterial blood pressures
also are increased during cycling; Systolic blood pressure
readings of >200 mm Hg can be found during maximal exercise
testing on the bicycle ergometer.78 79 During rowing,
heart rate increases to near-maximal values of
190 bpm, with peak
systolic blood pressure waves of
200
mm Hg.80 The combination of both extreme volume load and
extreme pressure load may explain why the largest increases in left
ventricular internal dimension and left
ventricular wall thickness are found in cyclists and
rowers.
Cardiac Function
Left ventricular systolic function is
generally assessed by measuring the extent and velocity of fiber
shortening, ejection fraction, and velocity of circumferential fiber
shortening.81 Our meta-analysis shows that in the
group of athletes studied, overall systolic function as judged
by fractional fiber shortening or ejection fraction is similar to that
of sedentary control subjects. We therefore conclude that there is no
relation between cardiac geometry and left ventricular
systolic function in athletes heart. However, the
parameters used in these studies reflect chamber mechanics
rather than myocardial mechanics. Studies of myocardial contractile
function in the hypertrophied left ventricle resulting from
hypertension suggest that intrinsic myocardial performance may
be depressed, even when left ventricular ejection fraction
remains normal.82 However, the presumed innocent nature of
the athletes heart does not allow the performance of more
invasive studies in athletes.
Left ventricular diastolic function is commonly
assessed by studying the pattern of ventricular filling
through the mitral valve.83 The generally used
diastolic function parameter is the E/A ratio.
Our meta-analysis demonstrated a normal or slightly enhanced
diastolic function in athletes compared with sedentary
control subjects. These results should be interpreted with some caution
because the E/A ratio not only is related to left
ventricular compliance but also is influenced by other
factors such as heart rate, preload, and afterload. A slower heart rate
may reduce the atrial contribution to left ventricular
filling by lengthening diastole. Generally, a normal or
slightly enhanced diastolic function in athletes may be
considered as a positive finding because in hypertensive patients the
increase in left ventricular mass and wall thickness is
associated with diastolic filling
abnormalities.84 85 86
Potential Study Limitations
Previous reviews only included those studies that used control
subjects matched for body size.87 88 However, in studies
of relative wall thickness, it is not mandatory to adjust for body size
because body size parameters appear in both the numerator
and denominator of the calculation, implying that relative wall
thickness is dimensionless. Also body size parameters do
not influence left ventricular systolic or
diastolic function. It was therefore possible to include
studies with control subjects of different body sizes or those without
control subjects; thus, the greater number of observations lead to
increased statistical power. Body size, however, does influence the
diameter and wall thickness of the left ventricle, and we can therefore
not exclude the possibility that part of the differences in heart size
may be ascribed to the larger body size of the athletes. Athletes
40
years of age and children were excluded from the analysis of
cardiac structure and function to eliminate other factors besides
training, such as hypertension or age-related increases in wall
thickness, which may be responsible for any differences in cardiac mass
or geometry.
It would have been interesting to study divergent cardiac adaptations
of athletes heart in women. However, to the best of our knowledge, no
literature is available regarding the effects of strength training on
the heart of female athletes.
Conclusions
The present meta-analysis on the anatomic structure
and function of the heart in endurance-trained athletes,
strength-trained athletes, and combined endurance- and strength-trained
athletes confirms the hypothesis of the existence of an
endurance-trained and a strength-trained heart. Divergent cardiac
adaptations do occur in athletes performing dynamic and static sports.
However, the classification as an endurance-trained heart or a
strength-trained heart is not an absolute and dichotomous concept but
rather a relative concept. In every form of endurance training, blood
pressure increases (pressure load), in addition to the increase in
cardiac output (volume load), just as in every form of strength
training, heart rate, cardiac output, and blood pressure increase.
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Footnotes
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1 References 2, 14, 21, 24, 2831, 3537, 44, 45,
48, and 5867.

2 References 914, 1723, 25, 26, 28, 3032, 34, 35, 3742, 4446, 4953, and 5872. 
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