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July 17, 1996, Vol 276, No. 3 >
ARTICLE | July 17, 1996

Athlete's Heart in Women: Title and subTitle BreakEchocardiographic Characterization of Highly Trained Elite Female Athletes FREE

Antonio Pelliccia, MD; Barry J. Maron, MD; Franco Culasso, PhD; Antonio Spataro, MD; Giovanni Caselli, MD
[+] Author Affiliations

Reprints: Barry J. Maron, MD, Minneapolis Heart Institute Foundation, 920 E 28th St, Suite 40, Minneapolis, MN 55407.


JAMA. 1996;276(3):211-215. doi:10.1001/jama.1996.03540030045030
Text Size: A A A
Published online
Article
References

Objectives  —To define the expression of "athlete's heart" in women by determining the alterations in cardiac dimensions associated with long-term intense conditioning in elite female athletes.

Design  —Prospective cardiovascular assessment conducted from 1986 through 1993. Subjects were evaluated using 2-dimensional, M-mode, and Doppler echocardiographic studies.

Setting  —Institute of Sports Science, Italian National Olympic Committee, Rome, Italy.

Participants  —A total of 600 elite female athletes (mean age, 21 years; range, 12-49 years) who had participated in vigorous training (mean duration, 9 years; range, 2-32 years) and had competed in 27 sports, including 211 athletes at the international level and 389 at the national level. A control group consisted of 65 sedentary volunteer women (mean age, 23.7 years; range, 14-41 years) who were free of cardiovascular disease and who did not participate in regular athletic training.

Main Outcome Measures  —Left ventricular end-diastolic cavity dimension and wall thickness.

Results  —Athletes demonstrated larger left ventricular end-diastolic cavity dimension (mean±SD)(49±4 mm) and greater maximal wall thickness (8.2±0.9 mm) than controls (46±3 mm and 7.2±0.6 mm; P<.001). These dimensions were 6% and 14% larger in athletes. Among athletes, left ventricular cavity dimension was 40 mm to 66 mm, exceeded normal limits (>54 mm) in 47 women (8%), and was within the range consistent with primary dilated cardiomyopathy (≥60 mm) in 4 athletes (1%). Training for endurance sports, such as cycling, cross-country skiing, and rowing had the greatest effect on cavity dimension. Left ventricular wall thickness was 6 mm to 12 mm in athletes and did not exceed normal limits or extend into the borderline gray zone with hypertrophic cardiomyopathy in any subject. Compared with data from 738 previously studied male athletes, female athletes showed significantly smaller left ventricular cavity dimension (11% less; P<.001) and wall thickness (23% less; P<.001).

Conclusions  —Highly trained women athletes frequently demonstrate cardiac dimensional changes as an adaptation to physical training, although absolute left ventricular cavity size exceeding normal limits was evident in a minority (8%) of women athletes and was rarely (1% of athletes) within the range of dilated cardiomyopathy. Athletic training was not a stimulus for substantial increases in absolute left ventricular wall thickness, which was within normal limits for all women athletes. These findings suggest that the clinical differentiation of athlete's heart and hypertrophic cardiomyopathy appears to be a diagnostic dilemma that is limited to male athletes.

REFERENCES

1 +
Rost R, Hollman W.  Athlete's heart . Int J Sports Med . 1983;;4:147-165.
2 +
Huston TP, Puffer JC, Rodney WM.  The athletic heart syndrome . N Engl J Med . 1985;;313:24-32.
3 +
Spirito P, Pelliccia A, Proschan MA, et al.  Morphology of the 'athlete's heart' assessed by echocardiography in 947 elite athletes representing 27 sports . Am J Cardiol . 1994;;74:802-806.
4 +
Maron BJ.  Structural features of the athlete's heart as defined by echocardiography . J Am Coll Cardiol . 1986;;7:190-203.
5 +
Keul J, Dickhuth H-H, Simon G, Lehman M.  Effect of static and dynamic exercise on heart volume, contractility, and left ventricular dimensions . Circ Res . 1981;;48( (pt 1) ):162-170.
6 +
Longhurst JC, Kelly AR, Gonyea WJ, Mitchell JH.  Chronic training with static and dynamic exercise . Circ Res . 1981;;48( (pt 1) ):171-178.
7 +
Fagard R, Aubert A, Lysens R, Staessen J, Vanhees L, Amery A.  Noninvasive assessment of seasonal variations in cardiac structure and function in cyclists . Circulation . 1983;;67:896-901.
8 +
Douglas PS, O'Toole ML, Hiller DB, Reichek N.  Left ventricular structure and function by echocardiography in ultraendurance athletes . Am J Cardiol . 1986;;58:805-809.
9 +
Pelliccia A, Spataro A, Caselli G, Maron BJ.  Absence of left ventricular wall thickening in athletes engaged in intense power training . Am J Cardiol . 1993;;72:1048-1054.
10 +
Orencia A, Bailey K, Yawn BP, Kottke TE.  Effect of gender on long-term outcome of angina pectoris and myocardial infarction/sudden unexpected death . JAMA . 1993;;269:2392-2397.
11 +
Kuhn FE, Rackley CE.  Coronary artery disease in women . Arch Intern Med . 1993;;153:2626-2636.
12 +
Gandhi MM, Wood DA, Lampe FC.  Characteristics and clinical significance of ambulatory myocardial ischemia in men and women in the general population presenting with angina pectoris . J Am Coll Cardiol . 1994;;23:74-81.
13 +
Pelliccia A, Maron BJ.  Preparticipation cardiovascular evaluation of the competitive athlete . Am J Cardiol . 1995;;75:827-828.
14 +
Maron BJ, Gottdiener JS, Epstein SE.  Patterns and significance of the distribution of left ventricular hypertrophy in hypertrophic cardiomyopathy . Am J Cardiol . 1981;;48:418-428.
15 +
Pelliccia A, Maron BJ, Spataro A, Proschan MA, Spirito P.  The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes . N Engl J Med . 1991;;324:295-301.
16 +
Sahn DJ, DeMaria A, Kisslo J, Weyman A.  Recommendations regarding quantitation in M-mode echocardiography . Circulation . 1978;;58:1072-1083.
17 +
Devereux RB.  Detection of left ventricular hypertrophy by M-mode echocardiography: anatomic validation, standardization, and comparison to other methods . Hypertension . 1987;;9( (suppl 2) , pt 2):19-26.
18 +
de Simone G, Daniels SR, Devereux RB, et al.  Left ventricular mass and body size in normotensive children and adults . J Am Coll Cardiol . 1992;;20:1251-1260.
19 +
Ford LE.  Heart size . Circ Res . 1976;;39:297-303.
20 +
Maron BJ, Spirito P, Green KJ, Wesley YE, Bonow RO, Arce J.  Noninvasive assessment of left ventricular diastolic function by pulsed Doppler echocardiography in patients with hypertrophic cardiomyopathy . J Am Coll Cardiol . 1987;;10:733-742.
21 +
Spirito P, Maron BJ.  Influence of aging on Doppler echocardiographic indices of left ventricular diastolic function . Br Heart J . 1988;;59:672-679.
22 +
Dixon WJ. BMDP Statistical Software Manual . Berkeley: University of California Press; 1992;:145-162, 489-527, 903-920.
23 +
Armitage P, Berry G. Statistical Methods in Medical Research . Oxford, England: McGraw-Hill Book Co; 1994;:277.
24 +
Henry WL, Gardin JM, Ware JH.  Echocardiographic measurements in normal subjects from infancy to old age . Circulation . 1980;;62:1054-1061.
25 +
Devereux RB, Lutas EM, Casale PN, et al.  Standardization of M-mode echocardiographic left ventricular anatomic measurements . J Am Coll Cardiol . 1984;;4:1222-1230.
26 +
Michels VV, Moll PP, Miller FA, et al.  The frequency of familial dilated cardiomyopathy in a series of patients with idiopathic dilated cardiomyopathy . N Engl J Med . 1992;;326:77-82.
27 +
Gavazzi A, De Maria R, Renosto G, et al.  The spectrum of left ventricular size in dilated cardiomyopathy . Am Heart J . 1993;;125;410-422.
28 +
Redfield MM, Gersh BJ, Bailey KR, Rodeheffer RJ.  Natural history of incidentally discovered, asymptomatic idiopathic dilated cardiomyopathy . Am J Cardiol . 1994;;74:737-739.
29 +
Zeldis SM, Morganroth J, Rubler S.  Cardiac hypertrophy in response to dynamic conditioning in female athletes . J Appl Physiol . 1978;;44:849-852.
30 +
Mickelson JK, Byrd BF III, Bouchard A, Botvinick EH, Schiller NB.  Left ventricular dimensions and mechanics in distance runners . Am Heart J . 1986;;112:1251-1256.
31 +
Pollak SJ, McMillan ST, Mumpower E, et al.  Echocardiographic analysis of elite women distance runners . Int J Sports Med . 1987;;8:81-83.
32 +
Fagard R, Van Den Broeke C, Vanhees L, Staessen J, Amery A.  Noninvasive assessment of systolic and diastolic left ventricular function in female runners . Eur Heart J . 1987;;8:1305-1311.
33 +
Riley-Hagan M, Peshock RM, Stray-Gundersen J, Katz J, Ryschon TW, Mitchell JH.  Left ventricular dimensions and mass using magnetic resonance imaging in female endurance athletes . Am J Cardiol . 1992;;69:1067-1074.
34 +
Crouse SF, Rohack JJ, Jacobsen DJ.  Cardiac structure and function in women basketball athletes . Res Q Exerc Sport . 1992;;63:393-401.
35 +
Morales MC, Gleim GW, Marino ND, Glace BT, Coplan NL.  The role of gender in echocardiographically determined left ventricular mass in equally trained populations of runners . Am Heart J . 1992;;124:1104-1106.
36 +
George KP, Wolfe LA, Burggraf GW, Norman R.  Electrocardiographic and echocardiographic characteristics of female athletes . Med Sci Sports Exerc . 1995;;27:1362-1370.
37 +
Astrand PO, Rodahl K, eds. Textbook of Work Physiology: Physiological Bases of Exercise . New York, NY: McGraw Hill Book Co; 1986;:414-415.
38 +
Knutsen KM, Stugaard M, Michelsen S, Otterstad JE.  M-mode echocardiographic findings in apparently healthy, non-athletic Norwegians aged 20-70 years . J Intern Med . 1989;;225:111-115.
39 +
Maron BJ, Pelliccia A, Spirito A.  Cardiac disease in young trained athletes: insights into methods for distinguishing athlete's heart from structural heart disease with particular emphasis on hypertrophic cardiomyopathy . Circulation . 1995;;91:1596-1601.
40 +
Maron BJ, Bonow RO, Cannon RO III, Leon BJ, Epstein SE.  Hypertrophic cardiomyopathy . N Engl J Med . 1987;;316:780-789,844-852.
41 +
Klues HG, Schiffers A, Maron BJ.  Phenotypic spectrum and patterns of left ventricular hypertrophy in hypertrophic cardiomyopathy: morphologic observations and significance as assessed by twodimensional echocardiography in 600 patients . J Am Coll Cardiol . 1995;;26:1699-1708.
42 +
Petrofsky JS, Burse RL, Lind AR.  Comparison of physiological responses of women and men to isometric exercise . J Appl Physiol . 1975;;38:863-868.
43 +
Hanley PC, Zinsmeister AR, Clements JP, Bove AA, Brown ML, Gibbons RJ.  Gender-related differences in cardiac response to supine exercise assessed by radionuclide angiography . J Am Coll Cardiol . 1989;;13:624-629.
44 +
Gleim GW, Stachenfeld NS, Coplan NL, Nicholas JA.  Gender differences in the systolic blood pressure response to exercise . Am Heart J . 1991;;121:524-530.
45 +
McGill HC, Anselmo VC, Buchanan JM, Sheridan PJ.  The heart is a target for androgen . Science . 1980;;207:775-777.
46 +
Koenig H, Goldstone A, Lu CY.  Testosterone-mediated sexual dimorphism of the rodent heart . Circ Res . 1982;;50:782-787.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Rost R, Hollman W.  Athlete's heart . Int J Sports Med . 1983;;4:147-165.
2 +
Huston TP, Puffer JC, Rodney WM.  The athletic heart syndrome . N Engl J Med . 1985;;313:24-32.
3 +
Spirito P, Pelliccia A, Proschan MA, et al.  Morphology of the 'athlete's heart' assessed by echocardiography in 947 elite athletes representing 27 sports . Am J Cardiol . 1994;;74:802-806.
4 +
Maron BJ.  Structural features of the athlete's heart as defined by echocardiography . J Am Coll Cardiol . 1986;;7:190-203.
5 +
Keul J, Dickhuth H-H, Simon G, Lehman M.  Effect of static and dynamic exercise on heart volume, contractility, and left ventricular dimensions . Circ Res . 1981;;48( (pt 1) ):162-170.
6 +
Longhurst JC, Kelly AR, Gonyea WJ, Mitchell JH.  Chronic training with static and dynamic exercise . Circ Res . 1981;;48( (pt 1) ):171-178.
7 +
Fagard R, Aubert A, Lysens R, Staessen J, Vanhees L, Amery A.  Noninvasive assessment of seasonal variations in cardiac structure and function in cyclists . Circulation . 1983;;67:896-901.
8 +
Douglas PS, O'Toole ML, Hiller DB, Reichek N.  Left ventricular structure and function by echocardiography in ultraendurance athletes . Am J Cardiol . 1986;;58:805-809.
9 +
Pelliccia A, Spataro A, Caselli G, Maron BJ.  Absence of left ventricular wall thickening in athletes engaged in intense power training . Am J Cardiol . 1993;;72:1048-1054.
10 +
Orencia A, Bailey K, Yawn BP, Kottke TE.  Effect of gender on long-term outcome of angina pectoris and myocardial infarction/sudden unexpected death . JAMA . 1993;;269:2392-2397.
11 +
Kuhn FE, Rackley CE.  Coronary artery disease in women . Arch Intern Med . 1993;;153:2626-2636.
12 +
Gandhi MM, Wood DA, Lampe FC.  Characteristics and clinical significance of ambulatory myocardial ischemia in men and women in the general population presenting with angina pectoris . J Am Coll Cardiol . 1994;;23:74-81.
13 +
Pelliccia A, Maron BJ.  Preparticipation cardiovascular evaluation of the competitive athlete . Am J Cardiol . 1995;;75:827-828.
14 +
Maron BJ, Gottdiener JS, Epstein SE.  Patterns and significance of the distribution of left ventricular hypertrophy in hypertrophic cardiomyopathy . Am J Cardiol . 1981;;48:418-428.
15 +
Pelliccia A, Maron BJ, Spataro A, Proschan MA, Spirito P.  The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes . N Engl J Med . 1991;;324:295-301.
16 +
Sahn DJ, DeMaria A, Kisslo J, Weyman A.  Recommendations regarding quantitation in M-mode echocardiography . Circulation . 1978;;58:1072-1083.
17 +
Devereux RB.  Detection of left ventricular hypertrophy by M-mode echocardiography: anatomic validation, standardization, and comparison to other methods . Hypertension . 1987;;9( (suppl 2) , pt 2):19-26.
18 +
de Simone G, Daniels SR, Devereux RB, et al.  Left ventricular mass and body size in normotensive children and adults . J Am Coll Cardiol . 1992;;20:1251-1260.
19 +
Ford LE.  Heart size . Circ Res . 1976;;39:297-303.
20 +
Maron BJ, Spirito P, Green KJ, Wesley YE, Bonow RO, Arce J.  Noninvasive assessment of left ventricular diastolic function by pulsed Doppler echocardiography in patients with hypertrophic cardiomyopathy . J Am Coll Cardiol . 1987;;10:733-742.
21 +
Spirito P, Maron BJ.  Influence of aging on Doppler echocardiographic indices of left ventricular diastolic function . Br Heart J . 1988;;59:672-679.
22 +
Dixon WJ. BMDP Statistical Software Manual . Berkeley: University of California Press; 1992;:145-162, 489-527, 903-920.
23 +
Armitage P, Berry G. Statistical Methods in Medical Research . Oxford, England: McGraw-Hill Book Co; 1994;:277.
24 +
Henry WL, Gardin JM, Ware JH.  Echocardiographic measurements in normal subjects from infancy to old age . Circulation . 1980;;62:1054-1061.
25 +
Devereux RB, Lutas EM, Casale PN, et al.  Standardization of M-mode echocardiographic left ventricular anatomic measurements . J Am Coll Cardiol . 1984;;4:1222-1230.
26 +
Michels VV, Moll PP, Miller FA, et al.  The frequency of familial dilated cardiomyopathy in a series of patients with idiopathic dilated cardiomyopathy . N Engl J Med . 1992;;326:77-82.
27 +
Gavazzi A, De Maria R, Renosto G, et al.  The spectrum of left ventricular size in dilated cardiomyopathy . Am Heart J . 1993;;125;410-422.
28 +
Redfield MM, Gersh BJ, Bailey KR, Rodeheffer RJ.  Natural history of incidentally discovered, asymptomatic idiopathic dilated cardiomyopathy . Am J Cardiol . 1994;;74:737-739.
29 +
Zeldis SM, Morganroth J, Rubler S.  Cardiac hypertrophy in response to dynamic conditioning in female athletes . J Appl Physiol . 1978;;44:849-852.
30 +
Mickelson JK, Byrd BF III, Bouchard A, Botvinick EH, Schiller NB.  Left ventricular dimensions and mechanics in distance runners . Am Heart J . 1986;;112:1251-1256.
31 +
Pollak SJ, McMillan ST, Mumpower E, et al.  Echocardiographic analysis of elite women distance runners . Int J Sports Med . 1987;;8:81-83.
32 +
Fagard R, Van Den Broeke C, Vanhees L, Staessen J, Amery A.  Noninvasive assessment of systolic and diastolic left ventricular function in female runners . Eur Heart J . 1987;;8:1305-1311.
33 +
Riley-Hagan M, Peshock RM, Stray-Gundersen J, Katz J, Ryschon TW, Mitchell JH.  Left ventricular dimensions and mass using magnetic resonance imaging in female endurance athletes . Am J Cardiol . 1992;;69:1067-1074.
34 +
Crouse SF, Rohack JJ, Jacobsen DJ.  Cardiac structure and function in women basketball athletes . Res Q Exerc Sport . 1992;;63:393-401.
35 +
Morales MC, Gleim GW, Marino ND, Glace BT, Coplan NL.  The role of gender in echocardiographically determined left ventricular mass in equally trained populations of runners . Am Heart J . 1992;;124:1104-1106.
36 +
George KP, Wolfe LA, Burggraf GW, Norman R.  Electrocardiographic and echocardiographic characteristics of female athletes . Med Sci Sports Exerc . 1995;;27:1362-1370.
37 +
Astrand PO, Rodahl K, eds. Textbook of Work Physiology: Physiological Bases of Exercise . New York, NY: McGraw Hill Book Co; 1986;:414-415.
38 +
Knutsen KM, Stugaard M, Michelsen S, Otterstad JE.  M-mode echocardiographic findings in apparently healthy, non-athletic Norwegians aged 20-70 years . J Intern Med . 1989;;225:111-115.
39 +
Maron BJ, Pelliccia A, Spirito A.  Cardiac disease in young trained athletes: insights into methods for distinguishing athlete's heart from structural heart disease with particular emphasis on hypertrophic cardiomyopathy . Circulation . 1995;;91:1596-1601.
40 +
Maron BJ, Bonow RO, Cannon RO III, Leon BJ, Epstein SE.  Hypertrophic cardiomyopathy . N Engl J Med . 1987;;316:780-789,844-852.
41 +
Klues HG, Schiffers A, Maron BJ.  Phenotypic spectrum and patterns of left ventricular hypertrophy in hypertrophic cardiomyopathy: morphologic observations and significance as assessed by twodimensional echocardiography in 600 patients . J Am Coll Cardiol . 1995;;26:1699-1708.
42 +
Petrofsky JS, Burse RL, Lind AR.  Comparison of physiological responses of women and men to isometric exercise . J Appl Physiol . 1975;;38:863-868.
43 +
Hanley PC, Zinsmeister AR, Clements JP, Bove AA, Brown ML, Gibbons RJ.  Gender-related differences in cardiac response to supine exercise assessed by radionuclide angiography . J Am Coll Cardiol . 1989;;13:624-629.
44 +
Gleim GW, Stachenfeld NS, Coplan NL, Nicholas JA.  Gender differences in the systolic blood pressure response to exercise . Am Heart J . 1991;;121:524-530.
45 +
McGill HC, Anselmo VC, Buchanan JM, Sheridan PJ.  The heart is a target for androgen . Science . 1980;;207:775-777.
46 +
Koenig H, Goldstone A, Lu CY.  Testosterone-mediated sexual dimorphism of the rodent heart . Circ Res . 1982;;50:782-787.

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