the expression  athlete s heart  is usually used to characterize cardiovascular effects of long - term exercise in competitive and highly trained athletes . however , the significance of anatomical and functional modifications caused by physical exercise , often beyond normal limits , remains controversial . physical exercise is a stimulating factor in the development of left ventricular hypertrophy , which is modulated by sport characteristics . this hypertrophy is considered a physiological and benign adaptation to systematic training , and is not associated with adverse cardiovascular consequences . several echocardiographic studies have shown that physical training is associated with left ventricular cavity enlargement and increased mass and wall thickness [ 516 ] . despite several studies showing cardiac adaptations induced by exercise , left and right ventricular adaptation in soccer players , cyclists , and long - distance runners has not been completely established . the aim of this study was to investigate cardiac structures and function in athletes from sports with different strength and endurance levels . we evaluated athletes from soccer , cycling , and long - distance running and compared the results with non - athlete controls . long - distance runners are characterized by endurance training , but soccer and cycling athletes are characterized by mixed strength / endurance training . the study was accomplished using echocardiogram , a non - invasive imaging exam , which is the main source of obtaining information on cardiac adaptation in response to intensive training in athletes [ 12,1719 ] . the study included 57 male competitive athletes from 3 different sports ( 21 soccer players , 19 long - distance runners , and 17 cyclists ) , aged 32.98.4 years , and 36 non - athlete male controls with similar anthropometric measurements and age ( 30.411.1 years ) . the project was approved by the research ethics committee of marilia school of medicine ( sao paulo state , brazil ) . the runners were members of the marilia runners association , the cyclists were professionals affiliated with the marilia and assis cycling teams , and the soccer players were professionals from the marilia athletic football club . the runners took part in marathons and 10 , 15 , and 21 km races . they trained approximately 2 to 3 hours per day ( 6 times per week ) , for a total of 80 to 120 km per week , and could complete a marathon in 3 hours . their main competitions were the national round sao paulo state race and the open inland sao paulo state games ; they also participated in competitions around the countryside of sao paulo and parana states ; all of these races were long - distance ( more than 1000 km over several days ) . the cyclists trained about 24 hours per week , or 600 km of training over 6 days , and did not undertake any other training during the year , except for a short period of preseason weightlifting . soccer players training sessions included isotonic and isometric exercises totaling approximately 26 hours per week . players from all positions were studied , except goalkeepers who underwent a different training routine . all echocardiograms were performed by the same examiner at marilia cardiology institute s echocardiography unit ( brazil ) [ 2022 ] . the echocardiograph was an envisor c model ( philips medical systems , andover , massachusetts , usa ) , equipped with a 2.04.0 mhz probe capable of acquiring second harmonic , tissue , pulsed , continuous , and color doppler , as well as 1- and 2-dimensional mode images . with individuals positioned in left lateral decubitus position and monitored with an electrocardiographic lead , the following echocardiographic cuts were performed : short parasternal axis to measure ventricles , aorta and left atrium ; apical 2 , 4 and 5 chambers to evaluate cavities and systolic and diastolic functions of ventricles . left ventricular ( lv ) mass ( lvm ) was calculated according to the devereux formula : where lvdd , ivsdt , and pwdt represent lv diastolic diameter , interventricular septum diastolic thickness , and posterior wall diastolic thickness , respectively . left atrium volume was obtained by the simpson s method from apical 2- and 4-chamber views . lv systolic function was evaluated by measuring the ejection fraction according to the simpson and teicholz method , endocardial fractional shortening , tei index , and systolic velocity of mitral annulus ( average of anterior , septal , inferior , and lateral walls ) . lv diastolic function was evaluated by measuring early ( e wave ) and late ( a wave ) diastolic mitral inflow velocity , their ratio , e wave deceleration time ( edt ) , isovolumic relaxation time ( ivrt ) , early ( e wave ) and late ( a wave ) diastolic mitral annulus velocity ( average of anterior , septal , inferior , and lateral walls ) by tissue doppler , and e / e ratio . the right ventricle ( rv ) rv systolic function was evaluated by calculating fractional area change and measuring systolic tricuspid annulus velocity . rv diastolic function was assessed by measuring tricuspid e and a waves and their ratio , edt , ivrt , e and a waves , and the e / e ratio . general characteristics between groups were compared by analysis of variance ( anova ) followed by the tukey test when distribution was normal , and anova on ranks ( kruskal - wallis ) followed by the dunn test when the distribution was non - normal . echocardiographic variables were compared by analysis of covariance ( ancova ) , using age as the covariant , complemented by the tukey test . the study included 57 male competitive athletes from 3 different sports ( 21 soccer players , 19 long - distance runners , and 17 cyclists ) , aged 32.98.4 years , and 36 non - athlete male controls with similar anthropometric measurements and age ( 30.411.1 years ) . the project was approved by the research ethics committee of marilia school of medicine ( sao paulo state , brazil ) . the runners were members of the marilia runners association , the cyclists were professionals affiliated with the marilia and assis cycling teams , and the soccer players were professionals from the marilia athletic football club . the runners took part in marathons and 10 , 15 , and 21 km races . they trained approximately 2 to 3 hours per day ( 6 times per week ) , for a total of 80 to 120 km per week , and could complete a marathon in 3 hours . their main competitions were the national round sao paulo state race and the open inland sao paulo state games ; they also participated in competitions around the countryside of sao paulo and parana states ; all of these races were long - distance ( more than 1000 km over several days ) . the cyclists trained about 24 hours per week , or 600 km of training over 6 days , and did not undertake any other training during the year , except for a short period of preseason weightlifting . soccer players training sessions included isotonic and isometric exercises totaling approximately 26 hours per week . players from all positions were studied , except goalkeepers who underwent a different training routine . all echocardiograms were performed by the same examiner at marilia cardiology institute s echocardiography unit ( brazil ) [ 2022 ] . the echocardiograph was an envisor c model ( philips medical systems , andover , massachusetts , usa ) , equipped with a 2.04.0 mhz probe capable of acquiring second harmonic , tissue , pulsed , continuous , and color doppler , as well as 1- and 2-dimensional mode images . with individuals positioned in left lateral decubitus position and monitored with an electrocardiographic lead , the following echocardiographic cuts were performed : short parasternal axis to measure ventricles , aorta and left atrium ; apical 2 , 4 and 5 chambers to evaluate cavities and systolic and diastolic functions of ventricles . left ventricular ( lv ) mass ( lvm ) was calculated according to the devereux formula : where lvdd , ivsdt , and pwdt represent lv diastolic diameter , interventricular septum diastolic thickness , and posterior wall diastolic thickness , respectively . left atrium volume was obtained by the simpson s method from apical 2- and 4-chamber views . lv systolic function was evaluated by measuring the ejection fraction according to the simpson and teicholz method , endocardial fractional shortening , tei index , and systolic velocity of mitral annulus ( average of anterior , septal , inferior , and lateral walls ) . lv diastolic function was evaluated by measuring early ( e wave ) and late ( a wave ) diastolic mitral inflow velocity , their ratio , e wave deceleration time ( edt ) , isovolumic relaxation time ( ivrt ) , early ( e wave ) and late ( a wave ) diastolic mitral annulus velocity ( average of anterior , septal , inferior , and lateral walls ) by tissue doppler , and e / e ratio . the right ventricle ( rv ) was structurally evaluated by measuring diastolic and systolic diameters and areas . rv systolic function was evaluated by calculating fractional area change and measuring systolic tricuspid annulus velocity . rv diastolic function was assessed by measuring tricuspid e and a waves and their ratio , edt , ivrt , e and a waves , and the e / e ratio . general characteristics between groups were compared by analysis of variance ( anova ) followed by the tukey test when distribution was normal , and anova on ranks ( kruskal - wallis ) followed by the dunn test when the distribution was non - normal . echocardiographic variables were compared by analysis of covariance ( ancova ) , using age as the covariant , complemented by the tukey test . runners were statistically older than soccer players and cyclists , and soccer players were younger than controls . body mass index was lower in runners and cyclists than soccer players , and also in runners compared to controls . body surface area was also significantly lower in runners and cyclists than in soccer players and controls . diastolic arterial pressure values did not differ between groups , whereas systolic arterial pressure was slightly lower in runners than in non - athletes . lv structural evaluation ( table 2 ) shows that cyclists and soccer players presented greater diastolic and systolic diameters than controls . diastolic lv wall thickness ( ivsdt and pwdt ) were increased in the 3 athlete groups compared to controls . lv mass was higher in athletes than controls , and higher in cyclists than runners . lv mass index was significantly higher in athletes , and cyclists showed higher values compared to soccer players and runners . left atrium ( la ) volume and la volume index were greater in athletes than controls . la volume was also greater in cyclists than runners , and la volume index was higher in cyclists than soccer players . tei index , a systo - diastolic index , also showed no difference between groups ( table 3 ) . in relation to lv diastolic function ( table 4 ) , mitral e and a waves , and edt were similar between groups . ventricular diastolic and systolic diameters and areas were significantly greater in athlete groups than controls . furthermore , the cyclists presented higher diastolic diameter and area than soccer players ( table 5 ) . rv systolic function evaluated by tissue doppler ( s wave ) was significantly decreased in runners than other athletes . rv diastolic function differed significantly only in ivrt evaluated by tissue doppler , which was greater in runners than controls ( table 5 ) . in this study we evaluated cardiac remodeling caused by different types of intense physical activity . athlete s heart involves a series of morphological and functional alterations resulting from vigorous and systematic physical training . cardiac adaptations depend on exercise classification , which can be divided into 2 types : dynamic ( also called resistance , aerobic or isotonic exercise ) , and static ( otherwise known as strength , anaerobic or isometric exercise ) . the majority of sports are not purely static or dynamic , but rather a mixture of both , and are considered to be mixed exercise . physiological changes resulting from dynamic exercise are seen in athletes who practice sports requiring long - term , medium to high intensity , physical activity . this exercise causes a marked increase of heart rate and cardiac output and a slight increase in arterial pressure . for instance , arterial pressure increases slightly in endurance athletes , and cardiac output of 5 to 6 liters per minute at rest can reach as much as 40 liters per minute at peak exertion . in contrast to dynamic exercise , cardiac alterations caused by static exercise can be seen in athletes performing highly intense short - term types of physical exercise . in this case , a mild increase in heart rate and cardiac output is observed , while arterial pressure substantially increases . in sports such as weightlifting in fact , a recent study by dandrea et al   showed increased sum of wall thickness and increased relative wall thickness in strength - trained athletes compared to endurance - trained athletes . however , the practice of mixed exercises is observed in most sports , characterized by long - term moderate or high intensity physical activity . in this type of exercise , a prolonged substantial increase in cardiac output and heart rate and a moderate increase in systolic arterial pressure , soccer players and cyclists presented larger diastolic and systolic lv diameters than non - athlete controls . also , lv diastolic wall thickness was higher in athletes . these data are similar to those found in several studies on athletes from different sports [ 7,8,14,28,3032 ] . mild la volume index enlargement was observed in 24.3% in a large population of highly trained athletes . in our study , la volume was greater in cyclists than runners , and la volume index was higher in cyclists than soccer players . this alteration can be explained by the type of physical activity , with combined dynamic and static exercise , mainly in cyclists , resulting in the greatest la enlargement . this result is in accordance with the study by pellicia et al .   who , in 1777 competitive athletes , found that la dimension was closely related to type of sport , with cycling , rowing , and canoeing producing the greatest impact . we evaluated lv systolic function by examining ejection fraction using teicholz and bi - planar simpson methods , endocardial fractional shortening , myocardial performance index , and tissular systolic wave . we did not find any differences between groups , thus corroborating data from the literature [ 8,10,14,15,17,3032,3537 ] . for lv diastolic function , there was no difference in e wave , a wave , or edt between groups . previous studies have shown an increased e / a ratio in endurance - trained compared with strength - trained athletes . e wave did not differ between groups , whereas a wave was slower in runners than non - athletes . studies have shown that hemodynamic overload in athletes during physical activity causes lv and rv dilatation [ 3741 ] . athletes in this study demonstrated increases in rv systolic and diastolic diameters and areas compared to controls ; we also observed a significant increase in rv diastolic diameter and area for cyclists compared to soccer players . assessment of rv systolic function is challenging due to complex geometry , poor endocardial definition , and the low accuracy seen in 2-dimensional echocardiography [ 23,4245 ] . the only difference seen in the many indexes was for systolic tricuspid annulus velocity , which was lower in runners than the other athletes . this tissue doppler index evaluates right ventricular function in a quick , simple manner , giving a high sensitivity and specificity comparable to nuclear magnetic resonance and radionuclide ventriculography . we studied rv diastolic function by analyzing transtricuspid flow velocity and diastolic tricuspid annulus velocity . isovolumetric relaxation time was the only index where we found a difference , being significantly higher in runners than controls and soccer players . because runners were older than soccer players , we can not discount the potential impact of age on decreased systolic tricuspid annulus velocity and increased isovolumetric relaxation time in runners compared to soccer players . in conclusion , soccer players , runners , and cyclists present cardiac remodeling characterized by lv hypertrophy and lv , left atrium , and right ventricle dilatation . cardiac remodeling is more intense in cyclists than runners and soccer players ; cyclists present a supernormal pattern of lv diastolic function in relation to non - athletes . no conclusive difference could be found in relation to right ventricular systolic and diastolic function .
backgroundstudies have shown cardiac changes induced by intense and regular physical activity . 
 the purpose of this study was to evaluate cardiac structures and function in soccer players , cyclists and long - distance runners , and compare them with non - athlete controls.material/methodscardiac structural , systolic , and diastolic function parameters in 53 athletes and 36 non - athlete controls were evaluated by doppler echocardiography.resultsathletes presented higher left atrial volume , left ventricular ( lv ) thickness , and lv and right ventricular ( rv ) diastolic diameters ( lvdd and rvdd , respectively ) compared to non - athletes . left atrium and lvdd were higher in cyclists than runners , and rvdd was higher in cyclists than soccer players . 
 lv mass index was higher in athletes , and cyclists had higher values than runners and soccer players . 
 lv systolic function did not differ significantly between groups . 
 the only altered index of lv diastolic function was a higher e / a ratio in cyclists compared to controls . 
 there was no difference in lv e / e ratio . 
 rv systolic function evaluated by tissue doppler imaging was higher in cyclists and soccer players than runners . 
 there were no conclusive differences in rv diastolic function.conclusionssoccer players , runners and cyclists had remodeling of left and right ventricular structures compared to controls . 
 cardiac remodeling was more intense in cyclists than runners and soccer players .