Imaging at the Heart of Sports Cardiology

As participation in competitive and recreational sports continues to grow, so does recognition of sports cardiology as a critical, rapidly evolving subspecialty. At the intersection of cardiovascular health and athletic performance, this field demands precise, nuanced assessment—particularly when lives and careers may hinge on the difference between imaging features related to benign adaptation and other pathological conditions.

A RadioGraphics article by Prabhakar Shantha Rajiah, MBBS, MD, a radiologist at Mayo Clinic in Rochester, MN, and colleagues outlines how advanced imaging techniques—particularly cardiac MRI (CMR) and coronary CT angiography (CCTA)—support accurate diagnosis and risk assessment in sports cardiology.

“Multimodality imaging is an essential tool in the sports cardiologist’s arsenal,” Dr. Rajiah said. “It provides critical support for risk assessment and differential diagnosis within a multidisciplinary framework.”

Distinguishing Disease from Adaptation

A major challenge in sports cardiology is distinguishing between physiologic adaptations to intense training—commonly known as athlete’s heart—and underlying cardiovascular disease. Misinterpretation in either direction can have significant consequences.

“A primary goal during pre-participation screening and evaluation of athletes is to differentiate between physiological adaptations and true pathology,” Dr. Rajiah said. “Mislabeling normal adaptation can unnecessarily sideline an athlete, while missing a pathological finding can have serious implications.”

Pre-participation screening typically includes clinical history, physical examination and electrocardiography (ECG), with exercise ECG added for older athletes. While echocardiography is often the first imaging step with abnormal initial assessment, advanced imaging becomes essential when echocardiographic findings are equivocal or raise concerns for more serious underlying pathology.  In such cases, CMR and CCTA are key next steps.

“CMR is particularly useful when echocardiographic findings are inconclusive, helping to differentiate athlete’s heart from mimicking pathologies,” Dr. Rajiah said. “Additionally, CMR supports diagnosis and risk stratification in symptomatic athletes or those recovering from significant cardiac events.”

CMR is particularly valuable in borderline cases, as the tissue characterization capabilities of MRI can provide essential information that either complement or extend beyond echocardiographic findings. “Diagnosis takes into account clinical pretest probability, sport type, competition level, age, sex, body size, ECG and exercise test findings, and imaging results,” Dr. Rajiah explained.

These imaging modalities can also guide decisions related to sports eligibility and long-term surveillance. “CCTA offers high-resolution evaluation of coronary artery anomalies and coronary artery disease (CAD), making it an invaluable component in certain clinical scenarios,” Dr. Rajiah added.

In trained athletes, findings such as symmetric left ventricular hypertrophy, mild chamber dilation and preserved or slightly reduced ejection fraction often reflect benign adaptation. However, similar findings in different clinical contexts may suggest cardiomyopathies, key differential diagnoses. CMR helps mitigate the ambiguity by precisely assessing these features alongside myocardial tissue characteristics, thereby supporting the  exclusion of cardiovascular disease in the appropriate clinical context.

“CMR is also valuable in evaluating athletes with symptoms such as palpitations or chest pain, or in those recovering from events like arrhythmia, myocardial infarction or resuscitated cardiac arrest,” Dr. Rajiah added.