Exercise testing in athletes: an adjunct to diagnose arrhythmogenic cardiomyopathy?

Differentiating physiological adaptation to exercise from cardiomyopathic hearts can be challenging. Specifically, evidence of how to deal with athletes under suspicion of arrhythmogenic cardiomyopathy (ACM) but not fulfilling diagnostic criteria is scarce and necessitates a better understanding of exercise pathophysiology and prospective trials. Upon available literature, we discuss and suggest research on combined stress echocardiography and cardiopulmonary exercise testing (CPET echocardiography) to demonstrate mismatch between cardiac output and metabolic demand. Integrating CPET echocardiography in suspected ACM cases may be feasible and could help to better differentiate physiological adaptation to exercise from cardiomyopathic hearts and may become a valuable adjunct for risk stratification and diagnostic frameworks. Future studies should implement combined CPET and stress echocardiography to differentiate physiological adaptations to exercise from cardiomyopathies in athletes with suspected ACM not fulfilling diagnostic criteria.