Differentiating an Athlete's Heart and Cardiomyopathy: Role of Advanced Cardiac Imaging

Background: Athletes can develop multifaceted adaptive cardiac remodeling with features overlapping with cardiomyopathy. Although clinical evaluation and echocardiography usually suffice in assessment, cases with uncertainty may benefit from advanced imaging to clarify the diagnosis and management. Case Summary: A 37-year-old male endurance athlete was referred after a screening coronary calcium scan incidentally revealed cardiac enlargement. Electrocardiography and echocardiography suggested exercise-induced physiological remodeling; however, cardiac magnetic resonance imaging revealed multifocal myocardial scarring concerning for cardiomyopathy. He underwent a comprehensive evaluation, was initiated on guideline-directed medical therapy, and ultimately resumed exercise through shared decision-making. Discussion: Advanced cardiac imaging is valuable when distinguishing an athlete's heart from cardiomyopathy is uncertain and supports individualized management decisions regarding safe exercise participation. Take-Home Messages: Distinguishing physiological remodeling from cardiomyopathy in athletes can be challenging. Multimodality imaging can provide important diagnostic insights and guide individualized management, but its use should be judicious and findings should be interpreted with caution.