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Differentiation between athlete’s heart and dilated cardiomyopathy in athletic individuals
  1. Lynne Martina Millar1,2,
  2. Zephryn Fanton1,2,
  3. Gherardo Finocchiaro2,3,
  4. Gabriel Sanchez-Fernandez2,
  5. Harshil Dhutia2,3,
  6. Aneil Malhotra2,4,
  7. Ahmed Merghani2,3,
  8. Michael Papadakis2,3,
  9. Elijah R Behr2,3,
  10. Nick Bunce2,
  11. David Oxborough5,
  12. Matthew Reed2,
  13. Jamie O'Driscoll6,
  14. Maria Teresa Tome Esteban2,3,
  15. Andrew D'Silva2,3,
  16. Gerry Carr-White7,
  17. Jessica Webb8,9,
  18. Rajan Sharma2,
  19. Sanjay Sharma2,3
  1. 1University of London St George's Molecular and Clinical Sciences Research Institute, London, UK
  2. 2Cardiology Clinical Academic Group, St George's University Hospitals NHS Foundation Trust, London, UK
  3. 3Molecular and Clinical Sciences Research Institute, University of London St George's Molecular and Clinical Sciences Research Institute, London, UK
  4. 4Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
  5. 5Research Institute of Sports and Exercise Science, Liverpool John Moores University, Liverpool, UK
  6. 6School of Human and Life Sciences, Canterbury Christ Church University, Canterbury, Kent, UK
  7. 7Department of Cardiology, Guy's and St Thomas' Foundation Trust, London, UK
  8. 8King's College London School of Medical Education, London, UK
  9. 9Cardiology Department, St Thomas' Hospital, London, UK
  1. Correspondence to Professor Sanjay Sharma, Molecular and Clinical Sciences Research Institute, University of London St George's Molecular and Clinical Sciences Research Institute, London SW17 0RE, UK; sasharma{at}


Objective Distinguishing early dilated cardiomyopathy (DCM) from physiological left ventricular (LV) dilatation with LV ejection fraction <55% in athletes (grey zone) is challenging. We evaluated the role of a cascade of investigations to differentiate these two entities.

Methods Thirty-five asymptomatic active males with DCM, 25 male athletes in the ‘grey zone’ and 24 male athletes with normal LV ejection fraction underwent N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement, ECG and exercise echocardiography. Grey-zone athletes and patients with DCM underwent cardiovascular magnetic resonance (CMR) and Holter monitoring.

Results Larger LV cavity dimensions and lower LV ejection fraction were the only differences between grey-zone and control athletes. None of the grey-zone athletes had abnormal NT-proBNP, increased ectopic burden/complex arrhythmias or pathological late gadolinium enhancement on CMR. These features were also absent in 71%, 71% and 50% of patients with DCM, respectively. 95% of grey-zone athletes and 60% of patients with DCM had normal ECG. During exercise echocardiography, 96% grey-zone athletes increased LV ejection fraction by >11% from baseline to peak exercise compared with 23% of patients with DCM (p<0.0001). Peak LV ejection fraction was >63% in 92% grey-zone athletes compared with 17% patients with DCM (p<0.0001). Failure to increase LV ejection fraction >11% from baseline to peak exercise or achieve a peak LV ejection fraction >63% had sensitivity of 77% and 83%, respectively, and specificity of 96% and 92%, respectively, for predicting DCM.

Conclusion Comprehensive assessment using a cascade of routine investigations revealed that exercise stress echocardiography has the greatest discriminatory value in differentiating between grey-zone athletes and asymptomatic patients with DCM. Our findings require validation in larger studies.

  • idiopathic dilated cardiomyopathy

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  • Twitter @drlynnemillar, @harshil_dhutia, @MichaelPapadak2, @SSharmacardio

  • Contributors All authors have been have made substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data and preparation of the manuscript. All authors contributed to manuscript preparation, manuscript revision, quality control and conduct of the study. LMM, ZF, MP, MR, JO’D, DO, MTTE, NB, ERB, GC-W, RS and SS contributed to the study design/planning. LMM, ZF, GF, GS-F, HD, AMa, AMe, AD’S, JW, DO, RS and SS contributed to data acquisition, analysis and interpretation. LMM, GF, RS and SS contributed to statistical analysis. LMM and SS are guarantors for the study.

  • Funding LMM, HD, AMa and GF were funded by research grants from CRY. AD’S and AMe were funded by research grants from the British Heart Foundation.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval Full ethical approval was granted by the Chelsea Research Ethics Committee, London, UK, and participants provided informed written consent.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The data, analytical methods and study materials will not be made available to other researchers for the purpose of reproducing the results or replicating the procedure. Researchers interested in the data, methods or analysis can contact the corresponding author for more information.

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