“Hearts that strain”: Distinguishing athlete's heart from hypertensive disease in the echo lab and beyond

Individuals with hypertension that engage in regular exercise comprise a special patient group that needs a careful approach to differentiate hypertensive cardiac damage from physiologic cardiac adaptations. Echocardiography is the diagnostic modality of choice in such cases. Hypertensive left ventricular hypertrophy is expected to resemble isometric exercise-associated hypertrophy in some but not all cases. On the other side, the hearts of regularly exercising individuals are expected to be normal or present with a variable mix of increased end-diastolic volume and increased wall thickness. It is therefore important to clearly document the type, frequency and duration of exercise performed. Diastolic dysfunction even without hypertrophy is often the first and only presentation in hypertension. On the contrary, diastolic function in athletes may be enhanced in order to maintain a stroke volume in high heart rates. Novel imaging techniques such as global longitudinal strain are helpful to identify subclinical systolic dysfunction that is inconsistent with athletic cardiac changes.