So-called gray zone between athlete's heart and hypertrophic cardiomyopathy- the significance of new imaging techniques in differential diagnosis

Urszula Fałkowska, Agnieszka Radzka, Marta Pawlicka, Anna Mroczek, Kamil Bałabuszek, Halina Piecewicz-Szczęsna


Athlete's heart characterized many adaptive changes in the heart in response to physical exertion. The discovery of the "heart of the athlete" phenomenon was made by Henschen already at the end of the 19th century during physical examination through percussion the chest of cross-country skiers.
The aim of the study
The aim of the paper is to present new imaging techniques aimed at more accurate diagnosis of the differential heart of patients with physiological adaptation to intense physical exercise of left ventricular hypertrophy and patients with hypertrophic cardiomyopathy.
Material and method
Standard criteria were used to review the literature data. The search of articles in English in the PubMed and Google Scholar database was carried out using the following keywords: athlete's heart, hypertrophic cardiomyopathy, tissue doppler method, magnetic resonance (MR) T1, extracellular volume (ECV) mapping, three-dimensional echocardiography (3D).
Description of the state of knowledge
Athlete’s heart may occasionally imitate pathological conditions related to sudden death, such as hypertrophic cardiomyopathy — the leading cause of sudden cardiac death in young athletes. Problems in differential diagnosis between the athlete's heart and hypertrophic cardiomyopathy are still existed. In the aspect of the differentiation of adaptive and pathological left ventricular hypertrophy in athletes, the diagnostic problem concerns the thickness of the myocardium (especially the interventricular septum) within 13-16 mm and constituting the so-called gray zone. This is a range of values that can be an expression of physiological LVH in competitive athletes and the symptom of a mild phenotype HCM.
This kind of lesions require an extended cardiac diagnosis, these include: echocardiography, tissue doppler imaging, cardiovascular magnetic resonance T1, extracellular volume and 3D echocardiography.


Athlete’s heart, hypertrophic cardiomyopathy, echocardiography, tissue doppler imaging, cardiovascular magnetic resonance T1, extracellular volume, 3D echocardiography

Full Text:



Puffer J. C.: Zespół serca sportowca. Medycyna po Dyplomie 2003; 3: 113-121.

Tomaszewski R., Wysocki K.: Serce sportowca. Medycyna Sportowa 1996; 54: 12-14.

Wożakowska-Kapłon B., Kempkiewicz T, Biskup P.: Serce Sportowca. Studia Medyczne 2006; 4: 81-90.

Fagard R.: Heart. Athlete's heart. Heart 2003; 89: 1455-61.

Maron BJ, Pelliccia A. The heart of trained athletes: cardiac remodeling and the risks of sports, including sudden death. Circulation. 2006; 114:1633-44.

Zbigniew Krenc. Adaptive left ventricular hypertrophy or hypertrophic cardiomyopathy? Choroby Serca i Naczyń 2015; 12: 25–34

Pelliccia A, Maron MS, Maron BJ. Assessment of left ventricular hypertrophy in a trained athlete: differential diagnosis of physiologic athlete's heart from pathologic hypertrophy. Prog Cardiovasc Dis. 2012;54:387–96.

Maron BJ, Pelliccia A. The heart of trainedathletes: cardiacremodeling and the risks of sports, including sudden death. Circulation. 2006;114:1633–44.

Caselli S, Maron MS, Urbano-Moral JA, Pandian NG, Maron BJ, Pelliccia A. Differentiating left ventricular hypertrophy in athletes from that in patients with hypertrophic cardiomyopathy. Am J Cardiol. 2014;114:1383–9.

Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 3: hypertrophic cardiomyopathy, arrhythmogenicright ventricular cardiomyopathy and other cardiomyopathies, and myocarditis. J Am Coll Cardiol. 2015;66:2362–71.

George KP, Warburton DE, Oxborough D, et al. Upper limits of physiological cardiac adaptation in ultramarathonrunners.J Am CollCardiol. 2011;57:754–5.

Cardim N, Oliveira AG, Longo S, et al. Doppler tissue imaging: regional myocardial function in hypertrophic cardiomyopathy and in athlete’s heart. J Am SocEchocadiogr. 2003;16:223–32.

Cotrim C, Almeida AR, Miranda R, et al. Stress-induced intraventricular gradients in symptomatic athletes during up right exercise continuous wave Doppler echocardiography. Am J Cardiol. 2010;106:1808–1812.

Lewis JF, Spirito P, Pelliccia A, et al. Usefulness of Doppler echocardiographic assessment of diastolic filling in distinguishing “athlete’s heart” from hypertrophiccardiomyopathy.Br Heart J. 1992;68:296–300.

Noureldin R.A., Liu S., Nacif M.S. et al. The diagnosis of hypertrophic cardiomyopathy by cardiovascular magnetic resonance. J. Cardiovasc. Magn. Reson.2012; 14: 17.

Peter P. Swoboda, Adam K. McDiarmid, Bara Erhayiem, et al. Assessing Myocardial Extracellular Volume by T1 Mapping to Distinguish Hypertrophic Cardiomyopathy From Athlete’s Heart. Journal of the American College of Cardiology2016; 67: 2189-2190.

Gersh B.J., Maron B.J., Bonow R.O., et al. ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. J Am CollCardiol 2011; 58:e212–e260.

Sado DM, Flett AS, Banypersad SM, et al. Cardiovascular magnetic resonance measurement of myocardialextracellularvolume in health and disease. Heart. 2012;98:1436–41.

Philip Haaf, PankajGarg, Daniel R. Messroghli et al. Cardiac T1 Mapping and Extracellular Volume (ECV) in clinical practice: a comprehensive review. Journal of Cardiovascular Magnetic Resonance 2016; 18:89

De Castro S, Pelliccia A, Caselli S, et al. Remodelling of the left ventricle in athlete'sheart: a threedimensionalechocardiographic and magnetic resonance imaging study. Heart. 2006;92:975–976.

Caselli S, Di Paolo FM, Pisicchio C, et al. Three-dimensionalechocardiographiccharacterization of leftventricularremodeling in Olympic athletes. Am J Cardiol. 2011;108:141–7.



  • There are currently no refbacks.

Copyright (c) 2018 © The Author(s)

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Journal of Education, Health and Sport formerly Journal of Health Sciences

Declaration on the original version.

Editors indicates that the main version of the magazine is to issue a "electronic".

The journal has had 5 points in Ministry of Science and Higher Education parametric evaluation. § 8. 2) and § 12. 1. 2) 22.02.2019.

1223 Journal of Education, Health and Sport eISSN 2391-8306 7

ISSN 2391-8306 formerly ISSN: 1429-9623 / 2300-665X

Archives 2011 - 2014

PBN 2011 - 2014

POL-index 2011 - 2014

BASE 2011 - 2014

Indexed in Bases, Bazy indeksacyjne: ERIH Plus, Worldcat, PBN/POL-Index, ICI Journals Master List, Directory of Open Access Journals (DOAJ), ZBD, Ulrich's periodicals, Google Scholar, Polska Bibliografia Lekarska

US NLM = 101679844

101679844 - NLM Catalog Result - NCBI

Find a library that holds this journal:

Journal Language(s): English 

PBN Poland



Redaction, Publisher and Editorial Office

Instytut Kultury Fizycznej Uniwersytet Kazimierza Wielkiego w Bydgoszczy, Institute of Physical Education Kazimierz Wielki University in Bydgoszcz, Poland 85-091 Bydgoszcz ul. Sportowa 2 Copyright by Instytut Kultury Fizycznej UKW w Bydgoszczy  Open Access ISSN 2391-8306 formerly ISSN: 1429-9623 / 2300-665X

The journal has been approved for inclusion in ERIH PLUS.

The ERIH PLUS listing of the journal is available at

SIC Science citation index (calculated on the basis of TCI and Page Rank) 0

Russian Impact factor 0.16

Indexed in Index Copernicus Journals Master List.,p24782242,3.html

ICV 2018 = 95.95 ICV 2017 = 91.30 ICV 2016 = 84.69 ICV 2015 = 93.34 ICV 2014 = 89.51 Standardized Value: 8.27 ICV 2013: 7.32 ICV 2012: 6.41 ICV 20115.48

The InfoBase Index IBI Factor for the year 2015 is 3.56 in InfoBase


Universal Impact Factor 1.78 for year 2012. (

Indexed in Polish Scholarly Bibliography (PBN) (PBN Polska Bibliografia Naukowa) (

is a portal of the Polish Ministry of Science and Higher Education, collecting information on publications of Polish scientists and on Polish and foreign scholarly journals. Polish Scholarly Bibliograhpy is a part of POL-on - System of Information on Higher Education. It is operated by the Interdisciplinary Centre for Mathematical and Computational Modelling, University of Warsaw.

Indexed in Russian Sciences Index Российский индекс научного цитирования (РИНЦ)

Indexed in Arianta Polish scientific and professional electronic journals Aneta Drabek i Arkadiusz Pulikowski