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Original Investigation
December 2, 2020

Cardiac Structure and Function in Elite Female and Male Soccer Players

Author Affiliations
  • 1Cardiovascular Performance Program, Massachusetts General Hospital, Boston
  • 2Echocardiography Laboratory, Massachusetts General Hospital, Boston
  • 3Cleveland Clinic Foundation, Cleveland, Ohio
  • 4University Heart Center, Zurich, Switzerland
  • 5United States Soccer Federation, Chicago, Illinois
  • 6Feinberg School of Medicine, Department of Emergency Medicine, Northwestern University, Evanston, Illinois
JAMA Cardiol. 2021;6(3):316-325. doi:10.1001/jamacardio.2020.6088
Key Points

Question  What are normal electrocardiographic and echocardiographic findings in elite female and male US soccer players?

Findings  In this cross-sectional study of 238 elite US soccer players, we found that male athletes frequently displayed common training-related electrocardiography changes, whereas female athletes had significantly more abnormal electrocardiograms per the International Recommendations for Electrocardiographic Interpretation in Athletes. Both female and male athletes frequently exceeded American Society of Echocardiography normative value standards for basic echocardiographic parameters.

Meaning  Elite US soccer players frequently present with training-related electrocardiography patterns and echocardiographic parameters that are above guideline-defined normal ranges.


Importance  Population-specific normative data are essential for the evaluation of competitive athletes. At present, there are limited data defining normal electrocardiographic (ECG) and echocardiographic values among elite US soccer players.

Objective  To describe ECG and echocardiographic findings in healthy elite US soccer players.

Design, Setting, and Participants  This cross-sectional study analyzed Fédération Internationale de Football Association–mandated screening sessions performed at US Soccer National Team training locations from January 2015 to December 2019. US women’s and men’s national team soccer players undergoing mandated cardiovascular screening were included.

Main Outcomes and Measures  Normal training-related and abnormal ECG findings were reported using the International Recommendations for Electrocardiographic Interpretation in Athletes. Echocardiographic measurements of structural and functional parameters relevant to cardiovascular remodeling were assessed relative to American Society of Echocardiography guideline–defined normal ranges.

Results  A total of 238 athletes (122 [51%] female; mean [SD] age, 20 [4] years; age range, 15-40 years) were included. Male athletes demonstrated a higher prevalence of normal training-related ECG findings, while female athletes were more likely to have abnormal ECG patterns (14 [11%] vs 0 in male cohort), largely accounted for by abnormal T-wave inversions. Echocardiography revealed no pathologic findings meeting criteria for sport restriction, but athletes frequently exceeded normal ranges for structural cardiac parameters responsive to exercise-induced remodeling including body surface area–indexed left ventricular (LV) mass (58 of 113 female athletes [51%] and 67 of 114 male athletes [59%]), indexed LV volume (89 of 115 female athletes [77%] and 76 of 111 male athletes [68%]), and LV wall thickness (37 of 122 female athletes [30%] and 47 of 116 male athletes [41%]). Age-stratified analysis revealed age-dependent increases in LV wall thickness, mass, and volumes among female athletes and LV wall thickness and mass among male athletes.

Conclusions and Relevance  These data represent the first set of comprehensive normative values for elite US soccer players and one of the largest sport-specific echocardiographic remodeling studies in female athletes. Abnormal ECG findings were more common in female athletes, while both female and male athletes frequently exceeded clinical normality cut points for remodeling-associated echocardiographic parameters.