The athlete’s heart in children and adolescents

Athlete’s heart occurs in childhood but is less well understood than in adults. In children, exercise-related cardiac remodelling occurs but with more heterogeneity than in adults. It can be difficult to distinguish age-related cardiac maturation, exercise-related adaptation, and the early manifestation of cardiac disease such as cardiomyopathy. The initial assessment of a child with possible athlete’s heart includes a detailed history (medical, family, and exercise), comprehensive physical examination, ECG, and echocardiography. Congenital and structural heart disease should be excluded and the pubertal stage should be considered when interpreting findings. Investigations should be interpreted according to somatic size (using centiles) and pubertal stage rather than chronological age. Ethnic variations in physiology should be identified. If in doubt, child athletes with possible ethnically related changes should be followed up until maturity. T-wave inversion in anteroseptal leads is usually normal before puberty but abnormal after puberty. Lateral T-wave inversion is usually abnormal at any age. Voltage criteria for left ventricular hypertrophy are common in healthy child athletes. The presence of pathological Q waves, T-wave inversion, and ST-segment depression requires exclusion of cardiomyopathy. Most child athletes’ heart chamber size is within the normal reference ranges for age/gender, but hypertrophic cardiomyopathy should be considered in adolescent athletes with wall thickness >12mm (girls >11mm).