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Original Investigation
September 23, 2020

Physiologic and Clinical Features of the Paralympic Athlete’s Heart

Author Affiliations
  • 1Institute of Sport Medicine and Science, Sport e Salute, Rome, Italy
  • 2Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Italy
  • 3Mediterranea Cardiocentro, Naples, Italy
  • 4Health and Science Department, International Association of Athletics Federations, Monaco
  • 5Department of Physiology and Pharmacology “V. Erspamer,” Sapienza University of Rome, Rome, Italy
  • 6Italian Wheelchair Basketball Federation (Federazione Italiana Pallacanestro in Carrozzina), Rome, Italy
  • 7Italian Paralympic Committee, Rome, Italy
JAMA Cardiol. 2021;6(1):30-39. doi:10.1001/jamacardio.2020.4306
Key Points

Question  What are the physiologic and clinical features of the Paralympic athlete's heart?

Findings  This cohort study included 252 consecutive Paralympic athletes who underwent cardiac evaluation. Cardiac remodeling in Paralympic athletes significantly differs, both in male and female athletes, depending on the type of injury and type of sport, with non–spinal cord injuries and endurance sports associated with the highest prevalence of training-associated electrocardiogram changes, the largest left ventricular cavity and mass, and the greatest peak oxygen uptake.

Meaning  This report provides characterization of the Paralympic athlete’s heart according to the type of lesion and type of sport, which may find immediate implementation in the setting of preparticipation cardiovascular evaluation of these athletes.


Importance  Paralympic medicine is a newly adopted term to describe the varied health care issues associated with athletes in the Paralympics. Scarce scientific data, however, are currently available describing the cardiac remodeling in Paralympic athletes.

Objective  To investigate the physiological and clinical characteristics of the Paralympic athlete's heart and derive the normative values.

Design, Setting, and Participants  This is a single-center study on a relatively large cohort of Paralympic athletes, conducted at the Italian Institute of Sport Medicine and Science. Paralympic athletes free of cardiac or systemic pathologic conditions other than their cause of disability were selected for participation in the Paralympic Games from January 2000 to June 2014. Athletes were arbitrarily classified for disability in 2 groups: those with spinal cord injuries (SCI) and those with non-SCI (NSCI). Data analysis occurred from March 2019 to June 2020.

Main Outcomes and Measures  The primary outcome was the difference in cardiac remodeling in Paralympic athletes according to disability type and sports discipline type. Athletes underwent cardiac evaluation, including 12-lead and exercise electrocardiograms, echocardiography, and cardiopulmonary exercise testing.

Results  Among 252 consecutive Paralympic athletes (median [interquartile range (IQR)] age, 34 [29-41] years; 188 men [74.6%]), 110 had SCI and 142 had NSCI. Those with SCI showed a higher prevalence of abnormal electrocardiogram findings than those with NSCI (13 of 110 [11.8%] vs 6 of 142 [4.2%]; P = .003), smaller left ventricular end-diastolic dimension (median [IQR], 48 [46-52] vs 51 [48-54] mm; P = .001) and left ventricular mass index (median [IQR], 80.6 [69-94] vs 91.3 [80-108] g/m2; P = .001), and lower peak oxygen uptake (VO2) (median [IQR], 27.1 [2-34] vs 38.5 [30-47] mL/min/kg; P = .001) in comparison with those with NSCI. Regarding sport discipline, endurance athletes had a larger left ventricular cavity (median [IQR], 52 [47-54] vs 49 [47-53] mm; P = .006) and higher peak VO2 (median [IQR], 46 [39-55] vs 30 [25-35] mL/min/kg; P = .001) than athletes in nonendurance sports.

Conclusions and Relevance  Cardiac remodeling in Paralympic athletes differed by disability and sport discipline. Having NSCI lesions and engaging in endurance sports were associated with the largest left ventricular cavity and left ventricular mass and highest VO2 peak. Having SCI lesions and engaging in nonendurance disciplines, on the contrary, were associated with the smallest left ventricular cavity and mass and lowest VO2 peak.