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Left ventricular hypertrophy is a serious condition, strongly associated with the development of coronary artery disease, cerebrovascular disease, cardiac failure, sudden cardiac death, and overall mortality.1-4 In addition, regression of left ventricular hypertrophy is associated with reduction in all cause and cardiovascular mortality. The existence, therefore, of left ventricular hypertrophy in apparently healthy people has generated considerable interest ever since its initial description.5 Debate has centred on two major issues. The first concerns thenature of left ventricular hypertrophy of athleticism: is it simply a physiological response to periodic myocardial loading or does it have a pathological component and therefore carry implications for long term prognosis? The second concerns the diagnosis of left ventricular hypertrophy of athleticism: is it possible to differentiate with confidence physiological left ventricular hypertrophy from pathological conditions?
Physiology and pathology—a continuum or separate entities?
Cardiac enlargement in response to long term training was first described a century ago and was considered to be a purely physiological response.5 Much later, the theory was developed that left ventricular hypertrophy is part of a continuum and that transition from the early (physiological) to late (pathological) forms can occur.6 Certainly there are a few studies in veteran athletes, which raise some questions about long term cardiovascular well being,7 ,8 but these are heavily outweighed by the volume of studies showing cardiovascular health and longevity in athletes.9-11 The discovery thatACE genotype influences the degree of development of left ventricular hypertrophy in athletes complicates the issue12 ,13 and suggests that the development of left ventricular hypertrophy is multifactorial, but most authors continue to believe that athletic left ventricular hypertrophy is a purely physiological condition.14-18
Differentiating physiology and pathology
The main clinical area of conflict centres on the ability to differentiate the physiological from the pathological at the macroscopic level—does a given person …