Athletes’ hearts undergo structural and functional changes in response to intense training, with variations depending on the sport. While these changes are physiological, they can mimic underlying cardiomyopathies, making it crucial to distinguish between the two to avoid misdiagnosis and inappropriate medical decisions. Cardiac imaging—particularly MRI and cardiac CT—plays a central role in this evaluation. Thanks to technological advances, these tools allow deep analysis of the athlete’s heart, aiding differential diagnosis and preventing cardiovascular complications.
Imaging to distinguish adaptation vs. disease
Evaluation starts with clinical exams and first-line imaging like ECG and echocardiography. However, these may be insufficient for distinguishing physiological adaptation from underlying myocardial disease. Cardiac MRI is particularly useful for assessing myocardial structure and function, while CT is mainly used for evaluating coronary arteries and tissue composition.
MRI helps analyze chamber morphology, contractile function, and detect tissue anomalies. It offers a global heart view, identifying key markers that differentiate physiological remodeling from pathology. CT provides a fast, accurate alternative, particularly for assessing vascular structures and myocardial composition using contrast and dual-energy technologies.
MRI and CT in athlete heart evaluation
Cardiac MRI is now the reference exam for detailed assessment of athletes’ heart changes. It precisely evaluates chamber size, myocardial mass, and contractility—essential for identifying physiological versus pathological hypertrophy. Gadolinium late enhancement (LGE) sequences play a crucial role in detecting myocardial fibrosis, a marker for potential cardiomyopathy.
MRI also enables advanced tissue characterization via T1 and T2 mapping and extracellular volume (ECV) calculation. These parameters reveal subtle myocardial changes invisible to echocardiography, useful in suspected hypertrophic or dilated cardiomyopathy. Although CT is less detailed for tissue characterization, it’s valuable—especially for ruling out coronary disease in athletes with chest pain. New dual-energy CT and iodine enhancement technologies offer rapid evaluation of myocardial structure and anomalies.
Challenges and outlook in athlete heart imaging
One main challenge in athlete heart imaging is results interpretation. Training-induced physiological changes may resemble pathological signs, and the line between adaptation and disease isn’t always clear. It’s vital to consider the full clinical picture, including training intensity/duration, family history, and symptoms.
Access to advanced imaging is another issue. MRI and CT remain costly and sometimes limited to specialized centers, although availability is improving in some countries. The rise of AI—already used to automate cardiac volume analysis and anomaly detection—along with fast acquisition techniques, promises improved exam efficiency and accessibility. Automating image interpretation and developing diagnostic algorithms could streamline diagnosis and improve athlete care.
Lastly, the long-term impact of athlete heart changes remains uncertain. Most adaptations are reversible after training cessation, but some may persist and lead to dysfunction. Cardiac imaging is thus vital not only for immediate assessment but also for long-term follow-up to detect potential late complications.
Cardiac imaging has become an essential tool for evaluating athletes’ hearts, distinguishing physiological adaptations from underlying disease. MRI and CT provide detailed myocardial insights, enabling more accurate diagnoses and better cardiovascular risk prevention. Despite interpretation and access challenges, ongoing imaging innovations pave the way for even more effective athlete care. Collaboration between cardiologists, radiologists, and imaging experts is crucial to ensure optimal monitoring and safety for all athletes—amateur or professional.
