Indications, protocols, and interpretation of cardiovascular imaging for the evaluation and management of athletes: a clinical consensus statement of the European Association of Preventive Cardiology (EAPC) and the European Association of Cardiovascular Imaging (EACVI) of the ESC: Part 1-Exercise imaging - 2026
Indications, protocols, and interpretation of cardiovascular imaging for the evaluation and management of athletes: a clinical consensus statement of the European Association of Preventive Cardiology (EAPC) and the European Association of Cardiovascular Imaging (EACVI) of the ESC: Part 1-Exercise imaging
D'ascenzi, Flavio; Sanz-De La Garza, María; Maestrini, Vivianaet al.
2026 • In European Heart Journal. Cardiovascular Imaging
[en] Exercise imaging, particularly exercise stress echocardiography (ESE), has become a pivotal non-invasive tool for evaluating cardiovascular function in athletes and for distinguishing physiological adaptations from pathological conditions. This Clinical Consensus Statement by the European Association of Preventive Cardiology and the European Association of Cardiovascular Imaging synthesizes current evidence and provides practical guidance on indications, protocols, and interpretation of exercise imaging modalities in both competitive and recreational athletes. The document emphasizes the role of ESE in assessing cardiac reserve, unmasking concealed cardiomyopathies, and stratifying risk in clinical scenarios such as T-wave inversion, exercise-induced repolarization abnormalities, and extreme ventricular remodelling. Special attention is given to imaging protocols tailored to the athletic population, including dynamic assessment of the right and left ventricles, atria, and valvular function during various exercise modalities, highlighting the importance of the functional evaluation in athletes and active individuals. Additionally, the consensus explores the integration of advanced techniques such as cardiopulmonary exercise testing and exercise cardiac magnetic resonance imaging, highlighting their complementary roles in comprehensive cardiovascular evaluation. The statement advocates for individualized testing strategies that consider sport-specific demands, demographic factors such as body size, sex, ethnicity, and the underlying pathology. It also underscores the importance of exercise imaging in guiding sports eligibility and in tailoring exercise prescription for competitive athletes, as well as for patients willing to participate in recreational sports or exercise programs.
Disciplines :
Cardiovascular & respiratory systems
Author, co-author :
D'ascenzi, Flavio ; Sports Cardiology and Rehab Unit, Department of Medical Biotechnologies, University of Siena, Siena, Italy
Sanz-De La Garza, María; Cardiovascular Institute, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
Maestrini, Viviana; Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy ; Institute of Sports Medicine and Science, National Italian Olympic Committee, Rome, Italy
Cameli, Matteo; Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
Dweck, Marc; BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
Cavarretta, Elena ; Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy ; Advanced Cardiovascular Therapies Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
Castelletti, Silvia ; Cardiothoracic Department, University Hospital Santa Maria Della Misericordia, Udine, Italy
Claessen, Guido ; Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
Van Craenenbroeck, Emeline; Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium ; Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, Antwerp, Belgium
Neglia, Danilo; Cardiovascular and Imaging Departments, Fondazione Toscana G. Monasterio, Pisa, Italy ; Sant'Anna School of Advanced Studies, Pisa, Italy
Salvo, Giovanni; Department of Woman and Child Health, Paediatric Cardiology and Congenital Heart Disease, University of Padova, Padova, Italy
Donal, Erwan ; CHU Rennes, Inserm ; University of Rennes, Rennes, France
Drezner, Jonathan ; UW Medicine Center for Sports Cardiology, University of Washington, Seattle, USA
Eijsvogels, Thijs; Department of Medical Biosciences, Exercise Physiology Research Group, Radboud University Medical Center, Nijmegen, the Netherlands
Edvardsen, Thor; ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Nydalen, Oslo, Norway ; Faculty of Medicine, University of Oslo, Oslo, Norway
Gati, Sabiha ; Department of Cardiology Royal, Brompton Hospital London, London, UK
Halle, Martin ; Department of Preventive Sports Medicine and Sports Cardiology, TUM School of Medicine and Health, TUM University Hospital 'Klinikum Rechts der Isar', Technical University of Munich, Munich, Germany ; DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Munich Heart Alliance, Munich, Germany
Gerche, Andre; Heart, Exercise and Research Trials Lab, St Vincents Institute of Medical Research, Melbourne, Australia ; HEART Lab, Victor Chang Cardiovascular Research Institute, Darlinghurst, Australia
Guazzi, Marco ; Department of Cardiology, University of Milan School of Medicine, San Paolo Hospital, Milan, Italy
Lancellotti, Patrizio ; Université de Liège - ULiège > Département des sciences cliniques > Cardiologie - Pathologie spéciale et réhabilitation
Niebauer, Josef ; University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University, University Hospital Salzburg, Salzburg, Austria
Oxborough, David ; Research Institute for Sports and Exercise Science, Liverpool John Moores University, Liverpool, UK
Pieles, Guido; Department of Athlete Screening and Sports Cardiology, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar ; Institute of Sport, Exercise and Health, University College London, London, UK
Sitges, Marta ; Cardiovascular Institute, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
Sharma, Sanjay ; Cardiovascular Sciences Research Centre, Cardiology Clinical Academic Group, St George's University of London, London, UK
Papadakis, Michael; Cardiovascular Sciences Research Centre, Cardiology Clinical Academic Group, St George's University of London, London, UK
Andreini, Daniele; Division of University Cardiology and Cardiac Imaging, IRCCS Galeazzi Sant'Ambrogio Hospital, Milan, Italy ; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
Pelliccia, Antonio ; Institute of Sports Medicine and Science, National Italian Olympic Committee , Rome ,
Indications, protocols, and interpretation of cardiovascular imaging for the evaluation and management of athletes: a clinical consensus statement of the European Association of Preventive Cardiology (EAPC) and the European Association of Cardiovascular Imaging (EACVI) of the ESC: Part 1-Exercise imaging
Lancellotti P, Pellikka PA, Budts W, Chaudhry FA, Donal E, Dulgheru R, et al The clinical use of stress echocardiography in non-ischaemic heart disease: recommendations from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2016; 17: 1191–1229.
Han D, Hyun MC, Miller RJH, Gransar H, Slomka PJ, Dey D, et al 10-year experience of utilizing a stress-first SPECT myocardial perfusion imaging. Int J Cardiol 2024; 401: 131863.
Maestrini V, Gati S, D’Ascenzi F, Almeida AG, Borjesson M, Castelletti S, et al Indications, protocols, and interpretation of cardiovascular imaging for the evaluation and management of athletes. A Clinical Consensus Statement of the European Association of Preventive Cardiology (EAPC) and the European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology (ESC). Part 2—Cardiovascular Magnetic Resonance, Cardiac CT and Nuclear Imaging. Eur Heart J Cardiovasc Imaging 2026; 27: 1469–1497.
Kim JH, Baggish AL, Levine BD, Ackerman MJ, Day SM, Dineen EH, et al Clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2025; 85: 1059–1108.
Oxborough D, George K, Cooper R, Bhatia R, Ramcharan T, Zaidi A, et al Echocardiography in the cardiac assessment of young athletes: a 2025 guideline from the British Society of Echocardiography (endorsed by cardiac risk in the young). Echo Res Pract 2025; 12: 7.
Cavarretta E, D'Ascenzi F, Bianco M, Castelletti S, Cavigli L, Cecchi F, et al The role of echocardiography in sports cardiology: an expert opinion statement of the Italian Society of Sports Cardiology (SIC sport). Int J Cardiol 2024; 410: 132230.
Franklin BA, Eijsvogels TMH, Pandey A, Quindry J, Toth PP. Physical activity, cardiorespiratory fitness, and cardiovascular health: a clinical practice statement of the ASPC Part I: Bioenergetics, contemporary physical activity recommendations, benefits, risks, extreme exercise regimens, potential maladaptations. Am J Prev Cardiol 2022; 12: 100424.
Pelliccia A, Sharma S, Gati S, Back M, Borjesson M, Caselli S, et al 2020 ESC guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J 2021; 42: 17–96.
D'Ascenzi F, Anselmi F, Piu P, Fiorentini C, Carbone SF, Volterrani L, et al Cardiac magnetic resonance normal reference values of biventricular size and function in male athlete's heart. JACC Cardiovasc Imaging 2019; 12: 1755–1765.
Pelliccia A, Caselli S, Sharma S, Basso C, Bax JJ, Corrado D. et al European Association of Preventive Cardiology (EAPC) and European Association of Cardiovascular Imaging (EACVI) joint position statement: recommendations for the indication and interpretation of cardiovascular imaging in the evaluation of the athlete's heart. Eur Heart J 2018; 39: 1949–1969.
Donal E, Rozoy T, Kervio G, Schnell F, Mabo P, Carre F. Comparison of the heart function adaptation in trained and sedentary men after 50 and before 35 years of age. Am J Cardiol 2011; 108: 1029–1037.
Perkins DR, Talbot JS, Lord RN, Dawkins TG, Baggish AL, Zaidi A, et al The influence of maturation on exercise-induced cardiac remodelling and haematological adaptation. J Physiol 2022; 600: 583–601.
D'Ascenzi F, Pelliccia A, Valentini F, Malandrino A, Natali BM, Barbati R, et al Training-induced right ventricular remodelling in pre-adolescent endurance athletes: the athlete's heart in children. Int J Cardiol 2017; 236: 270–275.
Finocchiaro G, Dhutia H, D'Silva A, Malhotra A, Steriotis A, Millar L, et al Effect of sex and sporting discipline on LV adaptation to exercise. JACC Cardiovasc Imaging 2017; 10: 965–972.
D'Ascenzi F, Cavigli L, Marchese A, Taddeucci S, Cappelli E, Roselli A, et al Electrical and structural remodelling in female athlete's heart: a comparative study in women vs men athletes and controls. Int J Cardiol 2024; 400: 131808.
Stein KM, Slotwiner DJ, Mittal S, Scheiner M, Markowitz SM, Lerman BB. Formal analysis of the optimal duration of tilt testing for the diagnosis of neurally mediated syncope. Am Heart J 2001; 141: 282–288.
La Gerche A, Wasfy MM, Brosnan MJ, Claessen G, Fatkin D, Heidbuchel H. et al The athlete's heart-challenges and controversies: JACC focus seminar 4/4. J Am Coll Cardiol 2022; 80: 1346–1362.
Papadakis M, Wilson MG, Ghani S, Kervio G, Carre F, Sharma S. Impact of ethnicity upon cardiovascular adaptation in competitive athletes: relevance to preparticipation screening. Br J Sports Med 2012; 46: i22–i28.
Flanagan H, Cooper R, George KP, Augustine DX, Malhotra A, Paton MF, et al The athlete's heart: insights from echocardiography. Echo Res Pract 2023; 10: 15.
Vega RB, Konhilas JP, Kelly DP, Leinwand LA. Molecular mechanisms underlying cardiac adaptation to exercise. Cell Metab 2017; 25: 1012–1026.
Claessen G, De Bosscher R, Janssens K, Young P, Dausin C, Claeys M, et al Reduced ejection fraction in elite endurance athletes: clinical and genetic overlap with dilated cardiomyopathy. Circulation 2024; 149: 1405–1415.
Brown B, Millar L, Somauroo J, George K, Sharma S, La Gerche A, et al Left ventricular remodeling in elite and sub-elite road cyclists. Scand J Med Sci Sports 2020; 30: 1132–1139.
Millar LM, Fanton Z, Finocchiaro G, Sanchez-Fernandez G, Dhutia H, Malhotra A, et al Differentiation between athlete's heart and dilated cardiomyopathy in athletic individuals. Heart 2020; 106: 1059–1065.
Sharma S, Drezner JA, Baggish A, Papadakis M, Wilson MG, Prutkin JM, et al International recommendations for electrocardiographic interpretation in athletes. Eur Heart J 2018; 39: 1466–1480.
Claessen G, Schnell F, Bogaert J, Claeys M, Pattyn N, De Buck F, et al Exercise cardiac magnetic resonance to differentiate athlete's heart from structural heart disease. Eur Heart J Cardiovasc Imaging 2018; 19: 1062–1070.
Plehn G, Vormbrock J, Perings S, Plehn A, Meissner A, Butz T, et al Comparison of right ventricular functional response to exercise in hypertrophic versus idiopathic dilated cardiomyopathy. Am J Cardiol 2010; 105: 116–121.
Rowin EJ, Maron BJ, Olivotto I, Maron MS. Role of exercise testing in hypertrophic cardiomyopathy. JACC Cardiovasc Imaging 2017; 10: 1374–1386.
Champion S. Stress echocardiography: a major tool for determining arrhythmogenic right ventricular dysplasia/cardiomyopathy. J Am Soc Echocardiogr 2017; 30: 1042–1043.
Martinez MW, Kim JH, Shah AB, Phelan D, Emery MS, Wasfy MM, et al Exercise-induced cardiovascular adaptations and approach to exercise and cardiovascular disease: JACC state-of-the-art review. J Am Coll Cardiol 2021; 78: 1453–1470.
Wehrle A, Waibel S, Gollhofer A, Roecker K. Power output and efficiency during supine, recumbent, and upright cycle ergometry. Front Sports Act Living 2021; 3: 667564.
von Scheidt F, Kiesler V, Kaestner M, Bride P, Kramer J, Apitz C. Left ventricular strain and strain rate during submaximal semisupine bicycle exercise stress echocardiography in healthy adolescents and young adults: systematic protocol and reference values. J Am Soc Echocardiogr 2020; 33: 848–857.e1.
Pellikka PA, Arruda-Olson A, Chaudhry FA, Chen MH, Marshall JE, Porter TR, et al Guidelines for performance, interpretation, and application of stress echocardiography in ischemic heart disease: from the American Society of Echocardiography. J Am Soc Echocardiogr 2020; 33: 1–41.e8.
Claessen G, La Gerche A, Voigt JU, Dymarkowski S, Schnell F, Petit T, et al Accuracy of echocardiography to evaluate pulmonary vascular and RV function during exercise. JACC Cardiovasc Imaging 2016; 9: 532–543.
Mukherjee M, Rudski LG, Addetia K, Afilalo J, D'Alto M, Freed BH, et al Guidelines for the echocardiographic assessment of the right heart in adults and special considerations in pulmonary hypertension: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2025; 38: 141–186.
Hahn RT, Lerakis S, Delgado V, Addetia K, Burkhoff D, Muraru D, et al Multimodality imaging of right heart function: JACC scientific statement. J Am Coll Cardiol 2023; 81: 1954–1973.
D'Ascenzi F, Pelliccia A, Solari M, Piu P, Loiacono F, Anselmi F, et al Normative reference values of right heart in competitive athletes: a systematic review and meta-analysis. J Am Soc Echocardiogr 2017; 30: 845–858.e2.
Dawkins TG, Curry BA, Wright SP, Meah VL, Yousef Z, Eves ND, et al Right ventricular function and region-specific adaptation in athletes engaged in high-dynamic sports: a meta-analysis. Circ Cardiovasc Imaging 2021; 14: e012315.
Claeys M, Claessen G, Claus P, De Bosscher R, Dausin C, Voigt JU, et al Right ventricular strain rate during exercise accurately identifies male athletes with right ventricular arrhythmias. Eur Heart J Cardiovasc Imaging 2020; 21: 282–290.
Alhumaid W, Small SD, Kirkham AA, Becher H, Pituskin E, Prado CM, et al A contemporary review of the effects of exercise training on cardiac structure and function and cardiovascular risk profile: insights from imaging. Front Cardiovasc Med 2022; 9: 753652.
Marwick TH, Chandrashekhar Y. Imaging during exercise: is there added value? JACC Cardiovasc Imaging 2023; 16: 264–267.
Stohr EJ, Gonzalez-Alonso J, Shave R. Left ventricular mechanical limitations to stroke volume in healthy humans during incremental exercise. Am J Physiol Heart Circ Physiol 2011; 301: H478–H487.
Badano LP, Muraru D, Ciambellotti F, Caravita S, Guida V, Tomaselli M, et al Assessment of left ventricular diastolic function by three-dimensional transthoracic echocardiography. Echocardiography 2020; 37: 1951–1956.
Reant P, Dufour M, Peyrou J, Reynaud A, Rooryck C, Dijos M, et al Upright treadmill vs. semi-supine bicycle exercise echocardiography to provoke obstruction in symptomatic hypertrophic cardiomyopathy: a pilot study. Eur Heart J Cardiovasc Imaging 2018; 19: 31–38.
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28: 1–39.e14.
Pelliccia A, Maron BJ, Di Paolo FM, Biffi A, Quattrini FM, Pisicchio C, et al Prevalence and clinical significance of left atrial remodeling in competitive athletes. J Am Coll Cardiol 2005; 46: 690–696.
D'Andrea A, Riegler L, Cocchia R, Scarafile R, Salerno G, Gravino R, et al Left atrial volume index in highly trained athletes. Am Heart J 2010; 159: 1155–1161.
D'Ascenzi F, Solari M, Anselmi F, Maffei S, Focardi M, Bonifazi M, et al Atrial chamber remodelling in healthy pre-adolescent athletes engaged in endurance sports: a study with a longitudinal design. The CHILD study. Int J Cardiol 2016; 223: 325–330.
D'Ascenzi F, Cameli M, Zaca V, Lisi M, Santoro A, Causarano A, et al Supernormal diastolic function and role of left atrial myocardial deformation analysis by 2D speckle tracking echocardiography in elite soccer players. Echocardiography 2011; 28: 320–326.
D'Ascenzi F, Anselmi F, Focardi M, Mondillo S. Atrial enlargement in the athlete's heart: assessment of atrial function may help distinguish adaptive from pathologic remodeling. J Am Soc Echocardiogr 2018; 31: 148–157.
D'Ascenzi F, Pelliccia A, Natali BM, Zaca V, Cameli M, Alvino F, et al Morphological and functional adaptation of left and right atria induced by training in highly trained female athletes. Circ Cardiovasc Imaging 2014; 7: 222–229.
D'Ascenzi F, Pelliccia A, Natali BM, Cameli M, Andrei V, Incampo E, et al Increased left atrial size is associated with reduced atrial stiffness and preserved reservoir function in athlete's heart. Int J Cardiovasc Imaging 2015; 31: 699–705.
Voigt JU, Malaescu GG, Haugaa K, Badano L. How to do LA strain. Eur Heart J Cardiovasc Imaging 2020; 21: 715–717.
Cameli M, Miglioranza MH, Magne J, Mandoli GE, Benfari G, Ancona R, et al Multicentric atrial strain COmparison between two different modalities: MASCOT HIT study. Diagnostics (Basel) 2020; 10: 946.
Wright S, Sasson Z, Gray T, Chelvanathan A, Esfandiari S, Dimitry J, et al Left atrial phasic function interacts to support left ventricular filling during exercise in healthy athletes. J Appl Physiol (1985) 2015; 119: 328–333.
Ariyaratnam JP, Mishima RS, McNamee O, Emami M, Thiyagarajah A, Fitzgerald JL, et al Exercise echocardiography to assess left atrial function in patients with symptomatic AF. Int J Cardiol Heart Vasc 2024; 50: 101324.
Sugimoto T, Bandera F, Generati G, Alfonzetti E, Barletta M, Losito M, et al Left atrial dynamics during exercise in mitral regurgitation of primary and secondary origin: pathophysiological insights by exercise echocardiography combined with gas exchange analysis. JACC Cardiovasc Imaging 2020; 13: 25–40.
Perrone MA, Iellamo F, D'Antoni V, Gismondi A, Di Biasio D, Vadala S, et al Acute changes on left atrial function during incremental exercise in patients with heart failure with mildly reduced ejection fraction: a case-control study. J Pers Med 2023; 13: 1272.
Bhatt A, Flink L, Lu DY, Fang Q, Bibby D, Schiller NB. Exercise physiology of the left atrium: quantity and timing of contribution to cardiac output. Am J Physiol Heart Circ Physiol 2021; 320: H575–HH83.
Gimelli A, Bottai M, Giorgetti A, Genovesi D, Kusch A, Ripoli A, et al Comparison between ultrafast and standard single-photon emission CT in patients with coronary artery disease: a pilot study. Circ Cardiovasc Imaging 2011; 4: 51–58.
Acampa W, Buechel RR, Gimelli A. Low dose in nuclear cardiology: state of the art in the era of new cadmium-zinc-telluride cameras. Eur Heart J Cardiovasc Imaging 2016; 17: 591–595.
Gimelli A, Liga R, Startari U, Giorgetti A, Pieraccini L, Marzullo P. Evaluation of ischaemia in patients with atrial fibrillation: impact of stress protocol on myocardial perfusion imaging accuracy. Eur Heart J Cardiovasc Imaging 2015; 16: 781–787.
Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, et al 2024 ESC guidelines for the management of chronic coronary syndromes. Eur Heart J 2024; 45: 3415–3537.
D'Andrea A, Caso P, Galderisi M, Di Maggio D, Cicala S, D'Andrea L, et al Assessment of myocardial response to physical exercise in endurance competitive athletes by pulsed Doppler tissue imaging. Am J Cardiol 2001; 87: 1226–1230; A8.
Adler Y, Fisman EZ, Koren-Morag N, Tanne D, Shemesh J, Lasry E, et al Left ventricular diastolic function in trained male weight lifters at rest and during isometric exercise. Am J Cardiol 2008; 102: 97–101.
Firoozi S, Sharma S, McKenna WJ. Risk of competitive sport in young athletes with heart disease. Heart 2003; 89: 710–714.
Urhausen A, Kindermann W. Echocardiographic findings in strength- and endurance-trained athletes. Sports Med 1992; 13: 270–284.
Butz T, van Buuren F, Mellwig KP, Langer C, Plehn G, Meissner A, et al Two-dimensional strain analysis of the global and regional myocardial function for the differentiation of pathologic and physiologic left ventricular hypertrophy: a study in athletes and in patients with hypertrophic cardiomyopathy. Int J Cardiovasc Imaging 2011; 27: 91–100.
Sharma S, Elliott PM, Whyte G, Mahon N, Virdee MS, Mist B, et al Utility of metabolic exercise testing in distinguishing hypertrophic cardiomyopathy from physiologic left ventricular hypertrophy in athletes. J Am Coll Cardiol 2000; 36: 864–870.
Kostakou PM, Kostopoulos VS, Tryfou ES, Giannaris VD, Rodis IE, Olympios CD, et al Subclinical left ventricular dysfunction and correlation with regional strain analysis in myocarditis with normal ejection fraction. A new diagnostic criterion. Int J Cardiol 2018; 259: 116–121.
Starekova J, Bluemke DA, Bradham WS, Eckhardt LL, Grist TM, Kusmirek JE, et al Evaluation for myocarditis in competitive student athletes recovering from coronavirus disease 2019 with cardiac magnetic resonance imaging. JAMA Cardiol 2021; 6: 945–950.
Urhausen A, Kindermann M, Bohm M, Kindermann W. Images in cardiovascular medicine. Diagnosis of myocarditis by cardiac tissue velocity imaging in an Olympic athlete. Circulation 2003; 108: e21–e22.
D'Andrea A, Severino S, Caso P, Liccardo B, Forni A, Fusco A, et al Prognostic value of supine bicycle exercise stress echocardiography in patients with known or suspected coronary artery disease. Eur J Echocardiogr 2005; 6: 271–279.
Sicari R, Nihoyannopoulos P, Evangelista A, Kasprzak J, Lancellotti P, Poldermans D, et al Stress echocardiography expert consensus statement–executive summary: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur Heart J 2009; 30: 278–289.
Picano E, Pierard L, Peteiro J, Djordjevic-Dikic A, Sade LE, Cortigiani L, et al The clinical use of stress echocardiography in chronic coronary syndromes and beyond coronary artery disease: a clinical consensus statement from the European Association of Cardiovascular Imaging of the ESC. Eur Heart J Cardiovasc Imaging 2024; 25: e65–e90.
Ahmadvazir S, Pradhan J, Khattar RS, Senior R. Long-term prognostic value of simultaneous assessment of atherosclerosis and ischemia in patients with suspected angina: implications for routine use of carotid ultrasound during stress echocardiography. J Am Soc Echocardiogr 2020; 33: 559–569.
D'Ascenzi F, Baggiano A, Cavigli L, Mandoli GE, Andreini D, Marallo C, et al The role of cardiac computed tomography in sports cardiology: back to the future!. Eur Heart J Cardiovasc Imaging 2022; 23: e481–e493.
Duncker DJ, Bache RJ. Regulation of coronary blood flow during exercise. Physiol Rev 2008; 88: 1009–1086.
Sharma S, Merghani A, Mont L. Exercise and the heart: the good, the bad, and the ugly. Eur Heart J 2015; 36: 1445–1453.
Riding NR, Sharma S, McClean G, Adamuz C, Watt V, Wilson MG. Impact of geographical origin upon the electrical and structural manifestations of the black athlete's heart. Eur Heart J 2019; 40: 50–58.
Sheikh N, Sharma S. Impact of ethnicity on cardiac adaptation to exercise. Nat Rev Cardiol 2014; 11: 198–217.
Arbelo E, Protonotarios A, Gimeno JR, Arbustini E, Barriales-Villa R, Basso C, et al 2023 ESC guidelines for the management of cardiomyopathies. Eur Heart J 2023; 44: 3503–3626.
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: 1383–1389.
Sheikh N, Papadakis M, Schnell F, Panoulas V, Malhotra A, Wilson M, et al Clinical profile of athletes with hypertrophic cardiomyopathy. Circ Cardiovasc Imaging 2015; 8: e003454.
Finocchiaro G, Dhutia H, D'Silva A, Malhotra A, Sheikh N, Narain R, et al Role of Doppler diastolic parameters in differentiating physiological left ventricular hypertrophy from hypertrophic cardiomyopathy. J Am Soc Echocardiogr 2018; 31: 606–613.e1.
Gaitonde M, Jones S, McCracken C, Ferguson ME, Michelfelder E, Sachdeva R, et al Evaluation of left ventricular outflow gradients during staged exercise stress echocardiography helps differentiate pediatric patients with hypertrophic cardiomyopathy from athletes and normal subjects. Pediatr Exerc Sci 2021; 33: 196–202.
Schnell F, Matelot D, Daudin M, Kervio G, Mabo P, Carre F, et al Mechanical dispersion by strain echocardiography: a novel tool to diagnose hypertrophic cardiomyopathy in athletes. J Am Soc Echocardiogr 2017; 30: 251–261.
Klaeboe LG, Lie OH, Brekke PH, Bosse G, Hopp E, Haugaa KH, et al Differentiation of myocardial properties in physiological athletic cardiac remodeling and mild hypertrophic cardiomyopathy. Biomedicines 2024; 12: 420.
Pelliccia A, Culasso F, Di Paolo FM, Maron BJ. Physiologic left ventricular cavity dilatation in elite athletes. Ann Intern Med 1999; 130: 23–31.
Abergel E, Chatellier G, Hagege AA, Oblak A, Linhart A, Ducardonnet A, et al Serial left ventricular adaptations in world-class professional cyclists: implications for disease screening and follow-up. J Am Coll Cardiol 2004; 44: 144–149.
Dores H, Mendes L, Dinis P, Cardim N, Monge JC, Santos JF. Myocardial deformation and volume of exercise: a new overlap between pathology and athlete's heart? Int J Cardiovasc Imaging 2018; 34: 1869–1875.
Moir S, Marwick TH. Combination of contrast with stress echocardiography: a practical guide to methods and interpretation. Cardiovasc Ultrasound 2004; 2: 15.
Bohm P, Schneider G, Linneweber L, Rentzsch A, Kramer N, Abdul-Khaliq H, et al Right and left ventricular function and mass in male elite master athletes: a controlled contrast-enhanced cardiovascular magnetic resonance study. Circulation 2016; 133: 1927–1935.
La Gerche A, Heidbuchel H, Burns AT, Mooney DJ, Taylor AJ, Pfluger HB, et al Disproportionate exercise load and remodeling of the athlete's right ventricle. Med Sci Sports Exerc 2011; 43: 974–981.
La Gerche A, Burns AT, D'Hooge J, Macisaac AI, Heidbuchel H, Prior DL. Exercise strain rate imaging demonstrates normal right ventricular contractile reserve and clarifies ambiguous resting measures in endurance athletes. J Am Soc Echocardiogr 2012; 25: 253–262.e1.
Van De Bruaene A, La Gerche A, Prior DL, Voigt JU, Delcroix M, Budts W. Pulmonary vascular resistance as assessed by bicycle stress echocardiography in patients with atrial septal defect type secundum. Circ Cardiovasc Imaging 2011; 4: 237–245.
La Gerche A, Burns AT, Mooney DJ, Inder WJ, Taylor AJ, Bogaert J, et al Exercise-induced right ventricular dysfunction and structural remodelling in endurance athletes. Eur Heart J 2012; 33: 998–1006.
Gabrielli L, Bijnens BH, Butakoff C, Duchateau N, Montserrat S, Merino B, et al Atrial functional and geometrical remodeling in highly trained male athletes: for better or worse? Eur J Appl Physiol 2014; 114: 1143–1152.
Di Gioia G, Ferrara A, Squeo MR, Spera RF, Maestrini V, Monosilio S, et al Right and left atrial strain by speckle-tracking echocardiography: sex differences and correlation with cardiorespiratory fitness in Olympic athletes. J Am Soc Echocardiogr 2025; 39: 125–135.
Jarasunas J, Aidietis A, Aidietiene S. Left atrial strain - an early marker of left ventricular diastolic dysfunction in patients with hypertension and paroxysmal atrial fibrillation. Cardiovasc Ultrasound 2018; 16: 29.
Debonnaire P, Joyce E, Hiemstra Y, Mertens BJ, Atsma DE, Schalij MJ, et al Left atrial size and function in hypertrophic cardiomyopathy patients and risk of new-onset atrial fibrillation. Circ Arrhythm Electrophysiol 2017; 10: e004052.
Maffeis C, Rossi A, Cannata L, Zocco C, Belyavskiy E, Radhakrishnan AK, et al Left atrial strain predicts exercise capacity in heart failure independently of left ventricular ejection fraction. ESC Heart Fail 2022; 9: 842–852.
Bekfani T, Hamadanchi A, Ijuin S, Bekhite M, Nisser J, Derlien S, et al Relation of left atrial function with exercise capacity and muscle endurance in patients with heart failure. ESC Heart Fail 2021; 8: 4528–4538.
Cho DH, Kim YG, Choi J, Kim HD, Kim MN, Shim J, et al Atrial cardiomyopathy with impaired functional reserve in patients with paroxysmal atrial fibrillation. J Am Soc Echocardiogr 2023; 36: 180–188.
Matsumoto K, Tanaka H, Imanishi J, Tatsumi K, Motoji Y, Miyoshi T, et al Preliminary observations of prognostic value of left atrial functional reserve during dobutamine infusion in patients with dilated cardiomyopathy. J Am Soc Echocardiogr 2014; 27: 430–439.
Kagami K, Harada T, Yoshida K, Amanai S, Kato T, Wada N, et al Impaired right atrial reserve function in heart failure with preserved ejection fraction. J Am Soc Echocardiogr 2022; 35: 836–845.
Vecchiarelli E, Bentley RF, Connelly KA, Dorian P, Yan A, Mak S, et al Atrial fibrillation in middle-aged athletes: impact on left atrial, ventricular and exercise performance. PLoS One 2024; 19: e0294367.
Crawford T, Mueller G, Sarsam S, Prasitdumrong H, Chaiyen N, Gu X, et al Magnetic resonance imaging for identifying patients with cardiac sarcoidosis and preserved or mildly reduced left ventricular function at risk of ventricular arrhythmias. Circ Arrhythm Electrophysiol 2014; 7: 1109–1115.
Althunayyan A, Alborikan S, Badiani S, Wong K, Uppal R, Patel N, et al Clinical and prognostic implications of cardiopulmonary exercise stress echocardiography in asymptomatic degenerative mitral regurgitation. Am J Cardiol 2023; 201: 8–15.
Toubal O, Mahjoub H, Thebault C, Clavel MA, Dahou A, Magne J, et al Increasing pulmonary arterial pressure at low level of exercise in asymptomatic, organic mitral regurgitation. J Am Coll Cardiol 2018; 71: 700–701.
Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 2022; 43: 561–632.
Cavarretta E, Peruzzi M, Versaci F, Frati G, Sciarra L. How to manage an athlete with mitral valve prolapse. Eur J Prev Cardiol 2021; 28: 1110–1117.
Jansen R, Urgel K, Cramer MJ, van Aarnhem E, Zwetsloot PPM, Doevendans PA, et al Reference values for physical stress echocardiography in asymptomatic patients after mitral valve repair. Front Surg 2018; 5: 6.
Diwan A, McCulloch M, Lawrie GM, Reardon MJ, Nagueh SF. Doppler estimation of left ventricular filling pressures in patients with mitral valve disease. Circulation 2005; 111: 3281–3289.
D'Ascenzi F, Valentini F, Pistoresi S, Frascaro F, Piu P, Cavigli L, et al Causes of sudden cardiac death in young athletes and non-athletes: systematic review and meta-analysis: sudden cardiac death in the young. Trends Cardiovasc Med 2022; 32: 299–308.
D'Ascenzi F, Valentini F, Anselmi F, Cavigli L, Bandera F, Benfari G, et al Bicuspid aortic valve and sports: from the echocardiographic evaluation to the eligibility for sports competition. Scand J Med Sci Sports 2021; 31: 510–520.
Spataro A, Pelliccia A, Rizzo M, Biffi A, Masazza G, Pigozzi F. The natural course of bicuspid aortic valve in athletes. Int J Sports Med 2008; 29: 81–85.
Schreurs BA, Hopman MTE, Bakker CM, Duijnhouwer AL, van Royen N, Thompson PD, et al Associations of lifelong exercise characteristics with valvular function and aortic diameters in patients with a bicuspid aortic valve. J Am Heart Assoc 2024; 13: e031850.
Cavigli L, Ragazzoni GL, Boncompagni A, Cavarretta E, Claessen G, D'Andrea A, et al Rationale and design of the SPREAD study: sport practice and its effects on aortic size and valve function in bicuspid aortic valve disease. J Sports Med Phys Fitness 2024; 64: 1107–1113.
D'Ascenzi F, Cavigli L, Cameli M, Claessen G, van Craenenbroeck EM, Cavarretta E, et al Sport practice and its effects on aortic size and valve function in bicuspid aortic valve disease: a cross-sectional report from the SPREAD study. Br J Sports Med 2024; 58: 1419–1425.
Pierard LA, Dulgheru R. Exercise testing and stress imaging in aortic valve disease. Curr Treat Options Cardiovasc Med 2017; 19: 54.
Yang CH, Teng LY, Lai MW, Weng KP, Tsai SW, Lin KL. Long-term results of serial exercise testing and echocardiography examinations in patients with pulmonary stenosis. J Cardiovasc Dev Dis 2023; 10: 31.
Teng LY, Tsai SW, Hsiao CY, Sung WH, Lin KL. Cardiopulmonary function assessment in children with pulmonary valve stenosis. Front Pediatr 2021; 9: 802645.
Roche SL, Grosse-Wortmann L, Redington AN, Slorach C, Smith G, Kantor PF, et al Exercise induces biventricular mechanical dyssynchrony in children with repaired Tetralogy of Fallot. Heart 2010; 96: 2010–2015.
O'Meagher S, Ganigara M, Munoz P, Tanous DJ, Chard RB, Celermajer DS, et al Right ventricular outflow tract enlargement prior to pulmonary valve replacement is associated with poorer structural and functional outcomes, in adults with repaired Tetralogy of Fallot. Heart Lung Circ 2014; 23: 482–488.
Muller J, Kuhn A, Tropschuh A, Hager A, Ewert P, Schreiber C, et al Exercise performance in Ebstein's anomaly in the course of time - deterioration in native patients and preserved function after tricuspid valve surgery. Int J Cardiol 2016; 218: 79–82.
Gargani L, Pugliese NR, De Biase N, Mazzola M, Agoston G, Arcopinto M, et al Exercise stress echocardiography of the right ventricle and pulmonary circulation. J Am Coll Cardiol 2023; 82: 1973–1985.
Budts W, Pieles GE, Roos-Hesselink JW, de la Garza M S, D'Ascenzi F, Giannakoulas G, et al Recommendations for participation in competitive sport in adolescent and adult athletes with Congenital Heart Disease (CHD): position statement of the sports cardiology & exercise section of the European Association of Preventive Cardiology (EAPC), the European Society of Cardiology (ESC) working group on adult congenital heart disease and the sports cardiology, physical activity and prevention working group of the Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J 2020; 41: 4191–4199.
Hastings JL, Levine BD. Syncope in the athletic patient. Prog Cardiovasc Dis 2012; 54: 438–444.
Cheezum MK, Liberthson RR, Shah NR, Villines TC, O'Gara PT, Landzberg MJ, et al Anomalous aortic origin of a coronary artery from the inappropriate sinus of Valsalva. J Am Coll Cardiol 2017; 69: 1592–1608.
Hobbs JB, Peterson DR, Moss AJ, McNitt S, Zareba W, Goldenberg I, et al Risk of aborted cardiac arrest or sudden cardiac death during adolescence in the long-QT syndrome. JAMA 2006; 296: 1249–1254.
Giudicessi JR, Ackerman MJ. Exercise testing oversights underlie missed and delayed diagnosis of catecholaminergic polymorphic ventricular tachycardia in young sudden cardiac arrest survivors. Heart Rhythm 2019; 16: 1232–1239.
Santoro F, Mango F, Mallardi A, D'Alessandro D, Casavecchia G, Gravina M, et al Arrhythmic risk stratification among patients with hypertrophic cardiomyopathy. J Clin Med 2023; 12: 3397.
Peterson DF, Kucera K, Thomas LC, Maleszewski J, Siebert D, Lopez-Anderson M, et al Aetiology and incidence of sudden cardiac arrest and death in young competitive athletes in the USA: a 4-year prospective study. Br J Sports Med 2021; 55: 1196–1203.
D'Ascenzi F, Zorzi A, Sciaccaluga C, Berrettini U, Mondillo S, Brignole M. Syncope in the young adult and in the athlete: causes and clinical work-up to exclude a life-threatening cardiac disease. J Cardiovasc Transl Res 2020; 13: 322–330.
Writing Committee Members; Shen WK, Sheldon RS, Benditt DG, Cohen MI, Forman DE, Goldberger ZD, et al 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. Heart Rhythm 2017; 14: e155–e217.
Baggish AL, Battle RW, Beaver TA, Border WL, Douglas PS, Kramer CM, et al Recommendations on the use of multimodality cardiovascular imaging in young adult competitive athletes: a report from the American Society of Echocardiography in collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2020; 33: 523–549.
Lampert R, Chung EH, Ackerman MJ, Arroyo AR, Darden D, Deo R, et al 2024 HRS expert consensus statement on arrhythmias in the athlete: evaluation, treatment, and return to play. Heart Rhythm 2024; 21: e151–e252.
Zeppilli P, Biffi A, Cammarano M, Castelletti S, Cavarretta E, Cecchi F, et al Italian cardiological guidelines (COCIS) for competitive sport eligibility in athletes with heart disease: update 2024. Minerva Med 2024; 115: 533–564.
Poliner LR, Dehmer GJ, Lewis SE, Parkey RW, Blomqvist CG, Willerson JT. Left ventricular performance in normal subjects: a comparison of the responses to exercise in the upright and supine positions. Circulation 1980; 62: 528–534.
Guazzi M, Bandera F, Ozemek C, Systrom D, Arena R. Cardiopulmonary exercise testing: what is its value? J Am Coll Cardiol 2017; 70: 1618–1636.
Wasserman K. Coupling of external to cellular respiration during exercise: the wisdom of the body revisited. Am J Physiol 1994; 266: E519–E539.
Astrand P-O, Cuddy TE, Saltin B, Stenberg J. Cardiac output during submaximal and maximal work. J Appl Physiol 1964; 19: 268–274.
Shimiaie J, Sherez J, Aviram G, Megidish R, Viskin S, Halkin A, et al Determinants of effort intolerance in patients with heart failure: combined echocardiography and cardiopulmonary stress protocol. JACC Heart Fail 2015; 3: 803–814.
Guazzi M. Stress echocardiography combined with cardiopulmonary exercise testing: opening a new window into diagnosis of heart failure with preserved ejection fraction. Eur J Prev Cardiol 2016; 23: 67–70.
D'Ascenzi F, Cavigli L, Pagliaro A, Focardi M, Valente S, Cameli M, et al Clinician approach to cardiopulmonary exercise testing for exercise prescription in patients at risk of and with cardiovascular disease. Br J Sports Med 2022; 56: 1180–1187.
Anselmi F, Cavigli L, Pagliaro A, Valente S, Valentini F, Cameli M, et al The importance of ventilatory thresholds to define aerobic exercise intensity in cardiac patients and healthy subjects. Scand J Med Sci Sports 2021; 31: 1796–1808.
Cavigli L, Olivotto I, Fattirolli F, Mochi N, Favilli S, Mondillo S, et al Prescribing, dosing and titrating exercise in patients with hypertrophic cardiomyopathy for prevention of comorbidities: ready for prime time. Eur J Prev Cardiol 2021; 28: 1093–1099.
La Gerche A, Claessen G, Van de Bruaene A, Pattyn N, Van Cleemput J, Gewillig M, et al Cardiac MRI: a new gold standard for ventricular volume quantification during high-intensity exercise. Circ Cardiovasc Imaging 2013; 6: 329–338.
Craven TP, Tsao CW, La Gerche A, Simonetti OP, Greenwood JP. Exercise cardiovascular magnetic resonance: development, current utility and future applications. J Cardiovasc Magn Reson 2020; 22: 65.
Van De Bruaene A, La Gerche A, Claessen G, De Meester P, Devroe S, Gillijns H, et al Sildenafil improves exercise hemodynamics in Fontan patients. Circ Cardiovasc Imaging 2014; 7: 265–273.
Carter EL, Moore RL, Whitehead KK, Partington SL, Biko DM, Vaiyani D, et al Exercise stress cardiovascular magnetic resonance imaging is feasible in adolescents and young adults with anomalous coronary arteries. J Cardiovasc Magn Reson 2025; 27: 101944.
La Gerche A, Claessen G, Dymarkowski S, Voigt JU, De Buck F, Vanhees L, et al Exercise-induced right ventricular dysfunction is associated with ventricular arrhythmias in endurance athletes. Eur Heart J 2015; 36: 1998–2010.
