3. The "Healthy" Athlete Paradox

Why all that's fit is not necessarily healthy.

This is a continuation and 3rd portion of the 3-bullet points made in the prior post. This post examines athletes and provides a different perspective, such that athletes may not be the health nuts that we deem them to be, and may in fact be at risk for cardiovascular disease. Note that this article discusses the use of PED’s and steroids, and although certain athletes were mentioned in this post this post does not make any claims about the use of PEDs or steroids for any of the athletes mentioned.

There’s no doubt that athletes serve as the paragon of the human physique. The ability to see the human form in action at the levels that many of us could only dream of creates a perception of the exceptional being, and one that many may aspire to be.

It’s no wonder that so much attention is being brought to the world of athletics and the sharp rise in deaths and heart damage experienced by many athletes since the rollout of the vaccines.

How could these exceptional athletes succumb to the damaging effects of a vaccine. Aren’t they the fittest of the fit? The healthiest of the health nut?

There’s a general assumption that, by virtue of athletes being in peak physical condition, they must be healthy.

Take a look at some of the most famous athletes such as soccer player Christiano Ronaldo, tennis extraordinaire Serena Williams, or heck even Hollywood actors such as Chris Hemsworth and we may infer that such bodies are indicative of what peak health should be¹.

It’s easy to assume that athletes that look good must be good health-wise, and yet contrast this notion with the fact that many of these athletes have to be the best of the best, which may come at the cost of doing all that is necessary to reach that spot and we may have to consider what exactly “it” takes to be the best of the best.

All this to say that looks can be deceiving. Although athletes may appear to be healthy, we may find that appearance isn’t everything, and that to be fit is not the same as being healthy.

When figuring out exactly what is happening to these athletes post-vaccination we need to examine all possible factors, and that includes ones that we may not deem socially acceptable to discuss.

Therefore, in this post we’ll take a look at athletes and the paradox of “health” and “fitness”, examining why being the best may come at a cost.

Conflating “fitness” and “health”

From Maffetone, P. B. & Laursen, P. B. Although athletes may appear to be optimal human beings, the constant training and possibly poor diet rich in processed carbohydrates may create a scenario in which overall health begins to deteriorate at the cost of being the best

During the Olympics it’s common to ask many athletes what they eat to get into shape or to maintain the calories necessary for their sport. One would think that most athletes would eat a relatively healthy assortment of fruits, vegetables, and meats and usually avoiding anything heavily processed. However, when calories are what’s needed the most you may sacrifice nutrition over energy.

For instance, Michael Phelps was assumed to have been eating tens of thousands of calories a day in preparation for the Olympics, and although most accounts of his actual caloric intake have been off by a few thousand the intake is certainly far above what any one of us would even consider doable on a daily basis:

Before the Beijing Games, Phelps said he was chowing down on an insane 12,000 calories a day, or 4,000 calories per meal. (He later said this could have been a bit of an exaggeration, but he was still eating quite a lot.) He'd start off with egg sandwiches loaded up with all the fixings, ranging from cheese to fried onions to mayo. After that, he'd go for chocolate-chip pancakes, French Toast, grits, and a five-egg omelet (gotta get that protein). Lunch would include a couple ham and cheese sandwiches, energy drinks, and a pound of pasta to top it off. For dinner, he'd down a whole pizza. And yet another pound of pasta.

Now, for an athlete such as Michael Phelps this may not be that surprising, however given the fact that many of these calories are highly processed carbs with no nutritional value one has to wonder if consumption to this degree of such foods may take a toll on the body.

And this begs the question; there’s no doubt that Michael Phelps is “fit”, but to what extent could we argue that he’d be “healthy” on such a processed diet?

It’s quite common to conflate these two terms, but in reality these terms define different measures.

A review from Maffetone, P. B. & Laursen, P. B.² provides the following differentiation bewteen the two terms and some perspective:

The term unhealthy athlete sounds, at first blush, like a paradox. The magazine cover image of an athlete performing her event in all its glory with flexed, lean muscles, bronzed skin, and glowing good looks may be perceived as the pinnacle of health. The internal working state of that athlete, however, may be at arm’s length from genuine health. In actuality, an athlete can be fit but unhealthy (Fig. 1).

While the terms “health” and “fitness” are often used interchangeably, we offer separate definitions:

• Health: a state of complete, mental, social, and physical well-being, where all bodily systems (nervous, hormonal, immune, digestive, etc.) function in harmony

• Fitness: the quality of being able to perform a specific physical task, which includes exercise and sports

So we can clearly see a discrepancy in how these terms should be used. Under most circumstances when we look at athletes competing in a sport we aren’t measuring their health, but rather their fitness. We are examining their ability to perform the given sport and do well at it, but in no ways can that tell us exactly what’s going on within the athlete’s body, or whether their blood sugar, blood pressure, or other bodily functions are working at optimal levels.

And so it becomes a severely big misnomer when we see an American football player suddenly keel over on the field, or when a soccer player clutches their chest indicating an acute cardiac phenomenon and make proclamations that these athletes are “healthy” and suddenly suffering severe issues. Onlookers will conflate the two terms above, and denounce the situation with some phrase of, “that person is clearly healthy! How could this have happened?!”

In essence, such pronouncements do nothing more than to obfuscate the nuanced factors that warrant examination. When we look at athletes and assume that they are well based on how they perform or appear we don’t do much justice in figuring out exactly what may have happened or what bodily functions may be dysfunctional.

Maffetone, P. B. & Laursen, P. B. go on to further elaborate this issue:

Poor health can be observed in athletes who adhere to sport’s global “no pain, no gain” mentality, who may push themselves beyond a point of appropriate system stress [1, 2]. This includes physical injury (e.g., neuromuscular dysfunction), biochemical injury (e.g., endocrine and immune dysfunction), and/or mental-emotional injury (e.g., depression). Each injury, in turn, could potentially cause other signs and symptoms indicative of poor health. The overreaching label we place on many athletes presenting with various combinations of these injuries is the overtraining syndrome [3]. The mechanisms leading to this condition can vary considerably, across different levels of training history and ability (recreational, non-elite, elite athletes), age, genders, and sports (dependent upon their aerobic and/or anaerobic metabolic requirements). The wide spectrum of various potential injuries is listed in Table 1 [4].

And in regards to diet they have this to say:

Today’s diet is typically high in refined carbohydrate, including various forms of sugar, which many athletes erroneously believe is necessary for better performance [11, 12]. However, a diet high in refined carbohydrate is also high glycemic, which can promote poor health [13, 14]. In the short term, refined carbohydrates, whether in the form of sugar or refined flour, can impair fat oxidation rates [13, 15] and contribute to the production of inflammation and pain [16, 17] and increased reactive oxygen species (ROS) production [14]. Over time, this can create hyperinsulinemia and chronic inflammation, also associated with reduced health [18]. Other dietary factors such as excess alcohol, excess omega-6 lipid consumption, trans fatty acids and others, along with various lifestyle factors including stress and excess exercise, can also contribute to chronic inflammation [14].

In essence, there’s no doubt that the “most winningest” Olympic athlete ever to compete is fit, but given the level of training and the poor diet as listed above can we immediately assume that such circumstances are an indication of peak health?

The infograph used in the prior post came from the same authors as the ones above, and in that article they make the same argument about the unhealthy athlete:

Despite high cardiorespiratory fitness, athletes of all ages and sex can suffer poor health, including cardiac conditions; some may even die during training or competition. While athletes are often thought of as being very healthy, this is not always the case as many are fit but unhealthy (Maffetone and Laursen, 2015; Scudiero et al., 2021). Sudden cardiac death (SCD) is one example.

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A few years ago FIFA³ commissioned an examination of sudden cardiac arrest among soccer players worldwide between 2014-2018, creating a database of athletes in order to find any underlying causes or associations with SCA/SCD.

Their key findings can be found outlined below:

Unfortunately, the study is mired with limitations. More than half of the reports did not provide a cause, and hardly any corroborating evidence via coroner’s autopsy reports were available. Also, the study hardly contained any elite athletes and predominately contained amateur athletes:

The majority of all cases occurred at amateur level (95 %, n=584), which was further divided into recreational players (45%, n=279, age 40±16 years) and competitive players (50%, n=305, age 28±14 years). Elite players represented only a small fraction (5%, n=33, age 26±6 years).

Given this finding, this study may predominately serve as an indication that sudden cardiac death among athletes is not a new, unique phenomenon and may be due to a combination of multiple factors such as underlying conditions paired with an endurance sport. But once again this FIFA report doesn’t provide much contextual information.

However, given this fact it should raise questions as to what other aspects of an athlete’s health may increase their risk of myocarditis and SCD. The above report lists various damages to the heart, and even some reports of physiological anomalies before the incident such as discomfort or chest pain was noted for some of these circumstances, suggesting that a game of soccer may have exacerbated underlying issues.

Considering that heart disease is a leading global killer, one may question whether activities that put additional stress on the heart may be indicative of widespread cardiovascular disease among athletes.

It’s worth noting that several studies have associated long-term endurance exercise with structural modifications within the heart and increased risk of cardiovascular disease.

For instance, this review from O’keefe, et. al.⁴ provided this remark on changes to an endurance athlete’s heart [context included]:

Chronic ET [endurance training] imposes increased hemodynamic demands that alter the loading conditions of the heart, particularly among athletes participating in sports requiring sustained elevations in cardiac work, such as long-distance running, rowing, swimming, and cycling.26 Highly trained individuals develop cardiac adaptations including enlarged LV [left ventricle] and RV [right ventricle] volumes, increased LV wall thickness and cardiac mass, and increased left atrial size.21-23 In the general population, these structural changes are associated with poor cardiac prognosis.27 However, these structural alterations, together with a preserved LV ejection fraction (EF), have been considered typical findings of the “athlete's heart.”18-20,28 Of concern, accumulating information suggests that some of the remodeling that occurs in endurance athletes may not be entirely benign.17,29-32 For example, in elite athletes, cardiac dimensions do not completely regress to normal levels even several years after the athlete has retired from competition and heavy ET.33

With a pathology outline for heart disease in athletes listed below showing how extreme exercise leads to elevated biochemical markers which may alter the structure and function of the heart, eventually leading into a recursive loop of accumulating heart disease:

From O’keefe, et. al. Continuously extreme exercise may elevate biomarkers that eventually may have detrimental effects on the heart. Long-term excessive exercise may eventually lead to modifications and remodeling to the heart that leads to increased risk of cardiovascular disease.

This phenomenon appears to be common enough to be termed the “athlete’s heart”⁵ (AH), as mentioned in the O'Keefe, et. al. review above and referred to in many articles⁶.

To what extent many top athletes suffer from overtraining syndrome (OTS) or AH is hard to determine. However, as the risk of myocarditis and SCD is of serious concern post-vaccination the risk of prior cardiovascular damage from such phenomenon as OTS and AH should warrant investigation as to whether underlying risk factors may synergize with elevated release of Catecholamines post-vaccination.

Now, we should keep in mind that this should absolutely not dissuade people from exercising or engaging in sports. Rather, this should be a reminder that too much of anything is not necessarily a good thing. It’s unlikely that many recreational sport enthusiasts or those who work out routinely will suffer CVD to the extent professional athletes may, but this is a reminder to take account of your own health and take care to understand what exactly is “too much”.

In short, we need to rethink how we define fitness and health. When we look at athletes and wonder how these so-called “healthy” individuals are suddenly dying at enormous rates we undermine nuanced discussion about the actual health status of many of these athletes.

The enhanced athlete

If we consider that athletes must be the “best of the best”, we have to concede that there may be a chance that they will also “do whatever it takes”, i.e. use performance enhancing substances/drugs (PEDs) to reach the pinnacle of athletic performance.

PEDs cover various substances that may increase the performance of an athlete. Generally when we think of PEDs we think of anabolic-androgen steroids (AAS) which are compounds that act similar to Testosterone (including Testosterone) and act on similar androgen receptors, leading to the downstream effects of leaner body mass, higher sex drive, and changes in mental cognition.

Some of these effects can be seen below, including the mechanism of action for AAS⁷:

From Momaya, A., Fawal, M., & Estes, R. Anabolic-androgen steroids (AAS) operate similar to that of Testosterone and are generally analogues of Testosterone. AAS bind to androgen receptors leading to the cascade of hormonal responses that upregulate and transcribe proteins that eventually lead to the similar effects of Testosterone such as lean body mass and increased muscle. However, in excess adverse side effects such as baldness, hypogonadism, and CVD may occur.

Social norms tend to make such discussions of PEDs rather difficult- no one wants to be told that their favorite athlete is on the sauce or juiced to the gills. It’s au natural and hard work that got them where they are (and no, this isn’t denying the hard work athletes must put in).

And yet the use of substances is likely far more pervasive than we are let on, especially at the highest levels of athleticism. The WHO considers PEDs to be substances of concern, and concerns over body dysmorphia, especially among young men who may be influenced by social media influencers

Take this review by Birzniece, V.⁸ It’s rather wordy but it sets up the situation quite well:

Doping in sport is a well-known phenomenon and is now reported on a daily basis by the media worldwide. Most reports, however, focus on elite athletes. Little attention has been devoted to the use of performance-enhancing and body-image-enhancing drugs in recreational athletes, the group with the highest rates of drug misuse. There is no doubt that doping among elite athletes will always be in focus. The power of a dream (Citius, Altius, Fortius) and potentially lucrative rewards may drive athletes to seek victory at any cost despite the Olympic creed that "the essential thing is not to have conquered, but to have fought well". Spectators appreciate observing athletes at their fastest, highest and strongest; but expect that this reflects their athletic ability and not their doping skills. Many elite athletes who abuse performance-enhancing substances have escaped detection and many recreational athletes are never going to be tested. Thus, we only can speculate how widespread doping actually is in elite and recreational sports.

Substantial research effort has been devoted to the development of reliable doping detection assays, as summarized elsewhere 1 . What is rarely discussed is the adverse effects and long-term health consequences of performance-enhancing drugs. This lack of emphasis on health risks of doping agents in the scientific literature has resulted in a prevalent belief among athletes that the only adverse consequence of doping is the risk of being caught. In a survey when athletes were asked if they are willing to misuse performance-enhancing drugs that would guarantee an Olympic medal if they could not be caught, 98% of athletes said yes 2 . When asked if they would take the drug even if they then died from its adverse effects but with a guarantee that they won every competition for the next 5 years without getting caught, an amazing 50% also replied yes 2 . In a recent paper summarizing athletes’ attitudes, it was reported that reasons for doping include not only athletic success, financial gain and improved recovery after injury, but also the assumption that other athletes also use them 3. Coaches appear to be the main influence and source of information for athletes, and many athletes feel pressed to dope 4 .

When we think of doping or the use of PED we may be inclined to imagine bodybuilders. It’s clear that aesthetics and “larger than life” bodies are prized in such a sport, yet we tend to forget that PEDs are widespread in all sports.

Remember that a few years ago Lance Armstrong was stripped of many of his Tour-de-France titles after he was found to have been doping for many years.

From CNN.com Some PED’s used by Lance Armstrong included Erythropoietin (hormone to stimulate red blood cell production), Corticosteroids and AAS, with the AAS indicated to have been used being Testosterone itself.

Many wouldn’t consider Lance Armstrong to be of peak aesthetic akin to bodybuilders, and yet the use of such substances may have provided him the upper-hand in such competitions.

Now, we should keep in mind that this doesn’t discredit hard work- if everyone in a sport is doping then those with the best genetics and performance capabilities will still win out in the end.

But what this tells us is that, once again, looks can be deceiving. In fact, many people may be surprised that even in combat sports such as mixed-martial arts (MMA) even athletes who suffer from “do you even lift" (DYEL) syndrome may be on PEDs to accelerate recovery and improve endurance/stamina in the octagon.

During the 2016 Olympics the doping spotlight was placed firmly over Russia, leading Russian athletes to be barred from many of the sporting events.

It’s rather ironic how many countries pointed fingers at Russia over such a scandalous finding, leading to many Russian doping scandal investigations.

It wasn’t for the fact that Russia was doping, but it was for the fact that Russia was one of the only countries to have gotten caught that is the real story. It’s highly unlikely that other countries pointing fingers weren’t involved in doping themselves.

So sure, maybe many of the world’s top athletes are doping or taking PED’s- what exactly is the harm in that?

As many PED’s act similar to endocrine hormones they have a powerful effect on many organs in the body that contain androgen receptors including the heart, and may be very detrimental if used at concentrations above what’s normally seen in the body (supraphysiological levels) or in those who may be more inclined to suffer adverse reactions due to genetic predispositions.

A review from Momaya, et. al. lists some of these adverse reactions from PED use:

Common side effects of AAS use include acne, testicular atrophy, gynecomastia, cutaneous striae, and injection site pain. Additionally, life-threatening side effects include cardiovascular disease with impaired diastolic filling, arrhythmias, stroke, blood clots, liver dysfunction, and cancer [27].

The most important cardiovascular changes involve increases in triglyceride levels, increases in concentrations of several clotting factors, and changes in myocardium, including increases in left ventricular mass and dilated cardiomyopathy. These effects vary depending on the type and dose of AAS and may be reversible with cessation of use. Other adverse effects include reductions in endogenous testosterone, gonadotropic hormones, and sex hormone-binding globulin. Reductions in these hormone levels result in decreased testicular size, sperm count, and sperm motility [28].

It’s interesting that both athlete’s heart and PED use show changes to the left ventricle of the heart. As the most vital chamber for pumping blood the LV may be susceptible to many heart changes. However, Catecholamines and the association with takotsubo cardiomyopathy may infer an association between PED’s mimicry of Testosterone and the possible release of Catecholamines. Granted, the LV being the most vital chamber for pumping may mean physiological alterations would occur in this region of the heart the most.

Although use of AAS has been associated with deleterious effects in all organs including the liver and kidney, it’s the heart that really may serve the brunt of these adverse reactions.

The science literature is inundated with evidence of increased cardiovascular risk from PED/AAS use⁹,¹⁰,¹¹, usually citing elevated blood pressure, cardiac hypertrophy, cardiac arrhythmias, and SCD as extreme consequences from PED use.

The same goes for many case reports of death in athletes who have used PEDs. For instance, this case report from Australia¹² presents with one case of an 18-year old football player who died from cardiac arrest (labeled a case of hypertrophic cardiomyopathy) while training and after running 2km, as well as a 24-year old who died mid-game (labeled as a case of myocarditis). It appears that there was no prior knowledge of PED use among these two men, however both were apparently using the AAS Oxymesterone.

Similar cases can be found, such as this case of a 20-year old bodybuilder¹³ dying from an instantaneous cardiac death with an idiopathic bilateral pulmonary hemorrhage immediately after administering several AAS, with the autopsy report noting indications of left ventricular hypertrophy and mild atherosclerosis. One literature review examining SCD in AAS users can be found here¹⁴, and another general literature review can be found here¹⁵ highlighting more instances of AAS-associated death.

Although we have looked at professional athletes and PED use, this doesn’t mean that teenagers are excluded from PED use. Given the fact that high school sports are the lifeline for many students to future careers or scholarships, and taking into account social pressures for approval and acceptance by teammates some students may be inclined to take AAS.

One survey¹⁶ was released to Southern California high schoolers during the 2006-2007 school year asking them their perception on steroids and whether they ever took them. The use of steroids was low (~1.7% of high school boys vs 1.1% girls), although the fact that high schoolers admitted to the use of steroids should raise some questions.

The perception of steroids was also rather interesting:

In the study sample, the most common perception about the beneficial effects of steroid use was that it increases athletic performance (49%, CI ¼ 0.48, 0.51), defined as ‘‘makes you better at sports.’’ Thirty-eight percent (CI ¼ 0.36, 0.39) of students held the perception that steroid use improves physical appearance (i.e., ‘‘makes you look better [like making your muscles bigger]’’). Only 11% (CI ¼ 0.10, 0.12) of students believed that steroids ‘‘do not make you become more angry or cause fights.’’ Only seventy students (1.7%) reported all three perceptions that steroids improve both athletics and aesthetics, and do not increase aggression.

During the 2006–2007 school year, 68% of males and 61% of females participated in at least one sport. Perceptions of steroid effects differed between student athletes and non-athletes. The belief that steroid use improves athletic performance was 31 percentage points higher among athletes compared to non-athletes (CI ¼ 0.22, 0.41; Fisher’s exact, p < 0.001), while the belief that steroid use improves physical appearance was 27% higher among athletes (CI ¼ 0.16, 0.39; Fisher’s exact, p < 0.001). The belief that steroids increase propensity for anger and violence did not differ between student athletes and non-athletes (CI ¼
0.23, 0.14; Fisher’s exact, p ¼ 0.51).

The survey also found that the sports with the strongest predictors of steroid use were wrestling, football, and soccer, with the possibility of steroid use increasing the more sports a student participated in (~33% for each sport).

So in some respect the pressures professional athletes feel to dope may occur in teenagers as well¹⁷. As social media use continues to grow among younger generations, so too does the image of being a social media influencer. For young men this may lead them to aspire to become fitness social media influencers and abusing PEDs to gain notoriety and a following.

This form of body dysmorphia, generally called muscle dysmorphia or “bigorexia” may be a real concern in the coming years, especially as younger men may turn to abusing steroids in order to become an "influencer".¹⁸

Now, let me be clear about the given information. There’s no way of knowing to what extent PED use is rampant among professional athletes. Health screens for athletes would check for PED use as well as possibly concerning cardiovascular findings. However, athletes are likely to alter their doping regimens in order to come up negative on tests, and when a star player is needed for a sport coaches and medical experts may waive any concerning findings and allow athletes to play anyways.

This means that health screens may not provide much if endeavors are taken to circumvent drug tests or if underlying concerns are overridden with the urge to win.

So this provides another important factor that is worth investigating, and one that we may deem socially unbecoming to discuss. But once again if the concern is figuring out all the possible factors for the deaths of these athletes PED use cannot be taken off the table.

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In Summary…

We’ve gone over quite a few things in this post, so I’ll provide a short summary below.

In short:

• Healthy is not the same as being fit. When looking at athletes we may assume that aesthetics are some indication of overall health when there really is no way to determine that by looks alone. We need to disabuse the notion that health is synonymous with fitness. Although many athletes are deemed fit, excessive exercise, poor eating habits and the possible abuse of PEDs may deem them to be far less healthy than we would assume. In trying to figure out what is happening to these athletes post-vaccination, we should be careful to immediately run to the assumption that these athletes are healthy, especially if such remarks lead people to obfuscate underlying factors that would need to be examined.

• PED use is a real problem. Personally, I’m of the belief that people can do what they want to their bodies, and at the pinnacle of most sports many athletes may be doping to keep up with one another. If everyone dopes, then it may not be an issue competitive-wise. However, this doesn’t mean that PED use and use of AAS don’t come with their own side effects. As most AAS mimic the effects of androgens so too do their side effects, and excess androgens are linked to increased risk of organ damage including the heart. If we are concerned with the cardiac damage occurring with these athletes we don’t do much by pretending that many may not be on PEDs, and when asked the question athletes may try to hide this fact even at the detriment of their own health. In elucidating the current predicament it may be worth understanding to what extent PED use is occurring among athletes, especially those who suffer severe adverse damage or even death.

• Teenage athletes should be considered as well. Many of the factors outlined here are associated with adult athletes at the professional level. However, given that high school athletes may undergo rigorous training regimens, and the fact that social pressures may weigh heavily on these adolescents and influence their behaviors, we may need to be concerned about overtraining and the use of PEDs among this cohort as well. Although the rate is likely to be far lower than adult athletes, we should be careful to not assume that this is not an issue. Remember, in the attempt of getting to the bottom of these post-vaccine issues, we need to consider all factors even those seemed socially unsavory to discuss.

• It’s the sum of all insults. Remember the excerpt from Cadegiani when contextualizing exactly what is going on. It’s not likely that the vaccines alone are causing myocarditis or SCD- we would likely see adverse rates FAR HIGHER than what we are seeing now. That means that we should look at all possible factors both independently and synergistically. In essence, does the combination of overtraining, PED use, and vaccination (along with ADHD and medications as well as obesity) all create the perfect storm to cause serious adverse reactions? It’s the sum of all insults on the body that may tell us what is happening.

So we’ve discussed the current predicament while outlining a few factors worth considering. As of now there continues to be investigations into what is happening to young men and athletes. In doing so doctors and researchers should keep in mind ALL possible factors and not pontificate on notions that these athletes are healthy for the sake of being athletes.

Because this post is running long, I’ll save my end remarks for another post and explain why comments that bury the lead on stories are detrimental for finding the truth.

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1. Okay, I’m not a sports person and had to choose people that just came to mind. For your own personal preference just replace the above athletes with whatever athletes you fancy.

2. Maffetone, P. B., & Laursen, P. B. (2015). Athletes: Fit but Unhealthy?. Sports medicine - open, 2, 24. https://doi.org/10.1186/s40798-016-0048-x

3. Egger F, Scharhag J, Kästner A, et al

FIFA Sudden Death Registry (FIFA-SDR): a prospective, observational study of sudden death in worldwide football from 2014 to 2018

British Journal of Sports Medicine 2022;56:80-87.

4. O'Keefe, J. H., Patil, H. R., Lavie, C. J., Magalski, A., Vogel, R. A., & McCullough, P. A. (2012). Potential adverse cardiovascular effects from excessive endurance exercise. Mayo Clinic proceedings, 87(6), 587–595. https://doi.org/10.1016/j.mayocp.2012.04.005

5. Fagard R. (2003). Athlete's heart. Heart (British Cardiac Society), 89(12), 1455–1461. https://doi.org/10.1136/heart.89.12.1455

6. Carbone, A., D'Andrea, A., Riegler, L., Scarafile, R., Pezzullo, E., Martone, F., America, R., Liccardo, B., Galderisi, M., Bossone, E., & Calabrò, R. (2017). Cardiac damage in athlete's heart: When the "supernormal" heart fails!. World journal of cardiology, 9(6), 470–480. https://doi.org/10.4330/wjc.v9.i6.470

This is a fairly thorough review that looks at the athlete’s heart and examines changes to various chambers as well as some damage from the heart.

This article has another interesting figure that summarizes many of these issues of athlete’s heart, and even shows differences between different exercises/sports:

7. Momaya, A., Fawal, M., & Estes, R. (2015). Performance-enhancing substances in sports: a review of the literature. Sports medicine (Auckland, N.Z.), 45(4), 517–531. https://doi.org/10.1007/s40279-015-0308-9

8. Birzniece V. (2015). Doping in sport: effects, harm and misconceptions. Internal medicine journal, 45(3), 239–248. https://doi.org/10.1111/imj.12629

9. Liu, J. D., & Wu, Y. Q. (2019). Anabolic-androgenic steroids and cardiovascular risk. Chinese medical journal, 132(18), 2229–2236. https://doi.org/10.1097/CM9.0000000000000407

10. Vanberg, P., & Atar, D. (2010). Androgenic anabolic steroid abuse and the cardiovascular system. Handbook of experimental pharmacology, (195), 411–457. https://doi.org/10.1007/978-3-540-79088-4_18

11. Achar, S., Rostamian, A., & Narayan, S. M. (2010). Cardiac and metabolic effects of anabolic-androgenic steroid abuse on lipids, blood pressure, left ventricular dimensions, and rhythm. The American journal of cardiology, 106(6), 893–901. https://doi.org/10.1016/j.amjcard.2010.05.013

12. Kennedy, M. C., & Lawrence, C. (1993). Anabolic steroid abuse and cardiac death. The Medical journal of Australia, 158(5), 346–348. https://doi.org/10.5694/j.1326-5377.1993.tb121797.x

13. Dickerman, R. D., Schaller, F., Prather, I., & McConathy, W. J. (1995). Sudden cardiac death in a 20-year-old bodybuilder using anabolic steroids. Cardiology, 86(2), 172–173. https://doi.org/10.1159/000176867

14. Torrisi, M., Pennisi, G., Russo, I., Amico, F., Esposito, M., Liberto, A., Cocimano, G., Salerno, M., Li Rosi, G., Di Nunno, N., & Montana, A. (2020). Sudden Cardiac Death in Anabolic-Androgenic Steroid Users: A Literature Review. Medicina (Kaunas, Lithuania), 56(11), 587. https://doi.org/10.3390/medicina56110587

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