{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T05:10:52Z","timestamp":1788844252588,"version":"build-2803163510"},"reference-count":32,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2026,9,5]],"date-time":"2026-09-05T00:00:00Z","timestamp":1788566400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background: Exercise-induced left ventricular hypertrophy (LVH) has been extensively investigated in adolescent athletes using the conventional two-tiered classification (2TC). However, the four-tiered classification (4TC) allows further differentiation of LVH patterns by incorporating three-dimensional information on left ventricular (LV) geometry. This study aimed to compare LVH assessment using the two classification systems and characterize the reclassification patterns. Methods: A total of 121 adolescent athletes (mean age: 15.1 \u00b1 1.6 years) and 114 adult athletes (mean age: 22.9 \u00b1 3.7 years), all competing at the national level, underwent comprehensive echocardiographic and anthropometric evaluations. Results: The application of 4TC resulted in redistribution across LV geometric categories compared with conventional 2TC. Twenty-three (19.0%) adolescent and 25 (22%) adult athletes were reclassified, including seven (5.8%) and 17 (15%), respectively, who shifted from normal geometry under the 2TC to different LVH categories under the 4TC. Reclassification was observed across sex and sporting discipline subgroups, although the patterns varied. In runners and triathletes, the combined prevalence of eccentric non-dilated and eccentric dilated LVH was 22.7% using the 4TC versus 4.5% eccentric LVH under the 2TC classification. LVM was strongly associated with the combined contribution of cumulative training duration, lean body mass, and body surface area (r = 0.785, p &lt; 0.001), whereas training duration alone was not significantly associated with the LVH parameters. Conclusions: The 2TC and 4TC approaches result in different assessments of LV geometry in highly trained athletes, with the 4TC providing additional characterization of LVH patterns by considering the presence or absence of LV dilatation. Reclassification patterns varied according to sex and sporting discipline, highlighting the importance of sport-related characteristics when interpreting exercise-induced LV remodeling in athletes.<\/jats:p>","DOI":"10.3390\/jcm15176879","type":"journal-article","created":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T12:12:25Z","timestamp":1788783145000},"page":"6879","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Benefits of Four-Tiered Classification of Exercise-Induced Left Ventricular Hypertrophy in Adolescent Athletes"],"prefix":"10.3390","volume":"15","author":[{"given":"Dora","family":"Szabo","sequence":"first","affiliation":[{"name":"Heart Institute, Medical School, University of Pecs, 7624 Pecs, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"software","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"}]},{"given":"Dora","family":"Babocsay","sequence":"additional","affiliation":[{"name":"Heart Institute, Medical School, University of Pecs, 7624 Pecs, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"investigation","vocabulary":"credit"}]},{"given":"Kata","family":"Eklics","sequence":"additional","affiliation":[{"name":"Department of Languages for Biomedical Purposes and Communication, Medical School, University of Pecs, 7624 Pecs, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"supervision","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2162-6155","authenticated-orcid":false,"given":"Istvan","family":"Szokodi","sequence":"additional","affiliation":[{"name":"Heart Institute, Medical School, University of Pecs, 7624 Pecs, Hungary"},{"name":"Szentagothai Research Centre, University of Pecs, 7624 Pecs, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Miklos","family":"Toth","sequence":"additional","affiliation":[{"name":"Szentagothai Research Centre, University of Pecs, 7624 Pecs, Hungary"},{"name":"Institute of Physiotherapy and Sport Science, Faculty of Health Science, University of Pecs, 7621 Pecs, Hungary"},{"name":"Department of Laboratory Medicine, Semmelweis University, 1089 Budapest, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"funding-acquisition","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"given":"Pongrac","family":"Acs","sequence":"additional","affiliation":[{"name":"Institute of Physiotherapy and Sport Science, Faculty of Health Science, University of Pecs, 7621 Pecs, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"validation","vocabulary":"credit"}]},{"given":"Attila","family":"Cziraki","sequence":"additional","affiliation":[{"name":"Heart Institute, Medical School, University of Pecs, 7624 Pecs, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"validation","vocabulary":"credit"}]},{"given":"Zsolt","family":"Sarszegi","sequence":"additional","affiliation":[{"name":"Heart Institute, Medical School, University of Pecs, 7624 Pecs, Hungary"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,5]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1202","DOI":"10.1177\/2047487318783524","article-title":"Echocardiographic evaluation of paediatric athlete\u2019s heart","volume":"25","year":"2018","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"204","DOI":"10.1007\/s00246-018-1982-9","article-title":"Normal Values for Left Ventricular Mass in Relation to Lean Body Mass in Child and Adolescent Athletes","volume":"40","author":"Krysztofiak","year":"2019","journal-title":"Pediatr. Cardiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1204","DOI":"10.1177\/2047487318776084","article-title":"Reference values of left heart echocardiographic dimensions and mass in male peripubertal athletes","volume":"25","author":"Cavarretta","year":"2018","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Kasiak, P., Kowalski, T., Zanini, M., Ozemek, C., Faiss, R., Debevec, T., Mamcarz, A., \u015ali\u017c, D., Chomiuk, T., and Ragazzoni, G.L. (2026). Normative values for cardiopulmonary exercise testing in the pediatric population-an updated systematic review. Eur. J. Prev. Cardiol., zwag168.","DOI":"10.1093\/eurjpc\/zwag168"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1633","DOI":"10.1161\/CIRCULATIONAHA.106.613562","article-title":"The heart of trained athletes: Cardiac remodeling and the risks of sports, including sudden death","volume":"114","author":"Maron","year":"2006","journal-title":"Circulation"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1619","DOI":"10.1016\/j.jacc.2009.10.068","article-title":"Long-term clinical consequences of intense, uninterrupted endurance training in olympic athletes","volume":"55","author":"Pelliccia","year":"2010","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1186\/1476-7120-3-17","article-title":"Echocardiography-based left ventricular mass estimation. How should we define hypertrophy?","volume":"3","author":"Foppa","year":"2005","journal-title":"Cardiovasc. Ultrasound"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1016\/j.pcad.2012.01.003","article-title":"Assessment of left ventricular hypertrophy in a trained athlete: Differential diagnosis of physiologic athlete\u2019s heart from pathologic hypertrophy","volume":"54","author":"Pelliccia","year":"2012","journal-title":"Prog. Cardiovasc. Dis."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"2108","DOI":"10.1016\/j.jacc.2016.02.062","article-title":"Etiology of Sudden Death in Sports: Insights from a United Kingdom regional registry","volume":"67","author":"Finocchiaro","year":"2016","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"164","DOI":"10.1161\/CIRCIMAGING.109.883652","article-title":"A 4-tiered classification of left ventricular hypertrophy based on left ventricular geometry: The Dallas heart study","volume":"3","author":"Khouri","year":"2010","journal-title":"Circ. Cardiovasc. Imaging"},{"key":"ref_11","first-page":"153","article-title":"Association of a 4-Tiered Classification of LV Hypertrophy with Adverse CV Outcomes in the General Population","volume":"10","author":"Garg","year":"2017","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Trachsel, L.D., Ryffel, C.P., De Marchi, S., Seiler, C., Brugger, N., Eser, P., and Wilhelm, M. (2018). Exercise-induced cardiac remodeling in nonelite endurance athletes: Comparison of 2-tiered and 4-tiered classification of left ventricular hypertrophy. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0193203"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1727","DOI":"10.1136\/heartjnl-2012-303465","article-title":"Systematic review and meta-analysis of training mode, imaging modality and body size influences on the morphology and function of the male athlete\u2019s heart","volume":"99","author":"Utomi","year":"2013","journal-title":"Heart"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"317","DOI":"10.1123\/ijspp.2021-0451","article-title":"Defining Training and Performance Caliber: A Participant Classification Framework","volume":"17","author":"McKay","year":"2022","journal-title":"Int. J. Sports Physiol. Perform."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e262","DOI":"10.1161\/CIR.0000000000000237","article-title":"Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 1: Classification of sports: Dynamic, static, and impact: A scientific statement from the American Heart Association and American College of Cardiology","volume":"132","author":"Levine","year":"2015","journal-title":"Circulation"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1007\/s004210050679","article-title":"Body surface area: Du Bois and Du Bois revisited","volume":"82","author":"Shuter","year":"2000","journal-title":"Eur. J. Appl. Physiol."},{"key":"ref_17","first-page":"F632","article-title":"Estimated lean body mass as an index for normalization of body fluid volumes in humans","volume":"247","author":"Boer","year":"1984","journal-title":"Am. J. Physiol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.echo.2014.10.003","article-title":"Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging","volume":"28","author":"Lang","year":"2015","journal-title":"J. Am. Soc. Echocardiogr."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/j.jcm.2016.02.012","article-title":"A guideline of selecting and reporting intraclass correlation coefficients for reliability research","volume":"15","author":"Koo","year":"2016","journal-title":"J. Chiropr. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2207","DOI":"10.1016\/j.jacc.2003.11.064","article-title":"Increased left ventricular mass is a risk factor for the development of a depressed left ventricular ejection fraction within five years: The Cardiovascular Health Study","volume":"43","author":"Drazner","year":"2004","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_21","first-page":"325","article-title":"Atrial chamber remodelling in healthy pre-adolescent athletes engaged in endurance sports: A study with a longitudinal design. The CHILD study","volume":"15","author":"Solari","year":"2016","journal-title":"Int. J. Cardiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1209","DOI":"10.1055\/a-1386-4805","article-title":"Influencing factors of cardiac adaptation in adolescent athletes","volume":"42","author":"Szabo","year":"2021","journal-title":"Int. J. Sports Med."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"McGregor-Cheers, R., Forsythe, L., Cooper, R., Johnson, C., Sculthorpe, N., Papadakis, M., Mill, N., Daniels, M., Kleinnibbelink, G., and George, K. (2023). Comparison of echocardiographic methods for calculating left ventricular mass in elite rugby football league athletes and the impact on chamber geometry. Front. Sports Act. Living, 5.","DOI":"10.3389\/fspor.2023.1270444"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Iso, Y., Kitai, H., Ichimori, K., Kubota, M., Tsujiuchi, M., Nagumo, S., Toshida, T., Yonechi, T., Ebato, M., and Suzuki, H. (2023). Cardiac Structure and Cardiorespiratory Fitness in Young Male Japanese Rugby Athletes. J. Cardiovasc. Dev. Dis., 10.","DOI":"10.3390\/jcdd10010012"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2001","DOI":"10.1177\/2047487319862061","article-title":"The developing athlete\u2019s heart: A cohort study in young athletes transitioning through adolescence","volume":"26","author":"Bjerring","year":"2019","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"2152","DOI":"10.1161\/CIRCULATIONAHA.114.010775","article-title":"Cardiac remodeling in response to 1 year of intensive endurance training","volume":"130","author":"Perhonen","year":"2014","journal-title":"Circulation"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"e003651","DOI":"10.1161\/CIRCIMAGING.115.003651","article-title":"Exercise-induced left ventricular remodeling among competitive athletes: A phasic phenomenon","volume":"8","author":"Weiner","year":"2015","journal-title":"Circ. Cardiovasc. Imaging"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1016\/j.ijcard.2018.04.111","article-title":"Age at start of endurance training is associated with patterns of left ventricular hypertrophy in middle-aged runners","volume":"267","author":"Ryffel","year":"2018","journal-title":"Int. J. Cardiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1016\/j.ijcard.2018.05.115","article-title":"Interpretation of left ventricular geometry in athletes","volume":"267","author":"Caselli","year":"2018","journal-title":"Int. J. Cardiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1093\/eurheartj\/ehaa605","article-title":"2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease","volume":"42","author":"Pelliccia","year":"2020","journal-title":"Eur. Heart J."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Krysztofiak, H., M\u0142y\u0144czak, M., Ma\u0142ek, \u0141.A., Folga, A., and Braksator, W. (2020). Left ventricular mass normalization in child and adolescent athletes must account for sex differences. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0236632"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e004229","DOI":"10.1161\/CIRCEP.116.004229","article-title":"Nonischemic left ventricular scar as a substrate of life-threatening ventricular arrhythmias and sudden cardiac death in competitive athletes","volume":"9","author":"Zorzi","year":"2016","journal-title":"Circ. Arrhythmia Electrophysiol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/17\/6879\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T04:29:52Z","timestamp":1788841792000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/17\/6879"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,5]]},"references-count":32,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["jcm15176879"],"URL":"https:\/\/doi.org\/10.3390\/jcm15176879","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,5]]}}}