A. Differentiation
There is little doubt that young, highly trained athletes develop physiologic thickening of the muscular wall of the left ventricle. This is similar to the enlarged biceps of a bodybuilder or a blacksmith. This normal physiologic enlargement of the heart muscle (hypertrophy), can be difficult to differentiate from a mild form of hypertrophic cardiomyopathy. Maron et al. observed that athletes within this hypertrophic gray zone presented an important and common difficult problem in which the differential diagnosis between hypertrophic cardiomyopathy and athlete’s heart must be resolved by noninvasive testing. Such testing often resolves the problem.
The athlete heart may show segmental thickening of the ventricular septum of 13–15 mm, which can be observed on echocardiography. The ECG in these athletes may show signs of ventricular hypertrophy, abnormal ST segment, and T-wave changes that may appear highly abnormal.
Differentiation can be observed in a number of ways.
1. The ECG shows the bizarre patterns seen in hyper-trophic cardiomyopathy.
2. The echocardiogram usually shows asymmetric hyper¬trophy in hypertrophic cardiomyopathy, whereas the athlete’s heart shows similar changes in both the left and right ventricle mass or a balanced enlarged heart. The left ventricular cavity is usually less than 45 mm in hypertrophic cardiomyopathy and in an athlete’s heart there may be dilatation of the cavity to greater than 55 mm.

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