Aortic Root Dilation in Strength and Power Athletes: Physiological Adaptation or Pathological Risk - a narrative review

Abstract

Background. Aortic root dilation is well described in endurance athletes, but its prevalence, magnitude, and clinical significance in strength and power athletes remain incompletely characterized, creating diagnostic uncertainty when an enlarged root is found in a heavily muscled competitor.

Aim. To synthesise evidence on aortic root dimensions, their determinants, and associated risks in strength and power athletes, weighing physiological adaptation against pathological aortopathy.

Materials and Methods. This narrative review synthesises peer-reviewed echocardiographic and epidemiological studies, registry-based series, case reports, mechanistic and biomechanical investigations, and international consensus and eligibility guidance addressing aortic root size, hemodynamic loading, connective-tissue disease, and dissection risk in resistance-trained populations.

Results. Across cohorts, strength and power athletes generally show aortic root diameters similar to, or only marginally larger than, sedentary controls, and often smaller than in endurance athletes, despite pronounced concentric left ventricular hypertrophy. Acute blood pressure surges during heavy resistance exercise transiently elevate aortic wall stress, and case series link anabolic-androgenic steroid use, uncontrolled hypertension, and undiagnosed connective-tissue or bicuspid aortic valve disease to catastrophic dissection during lifting. Diameter-to-ventricle ratios and indexed measurements improve discrimination between physiological remodeling and pathological dilation.

Conclusions. True aortic root enlargement is uncommon and rarely severe in strength and power athletes as an isolated training effect; when present, it should prompt exclusion of hypertension, steroid use, and heritable aortopathy rather than automatic attribution to sport, guiding individualized eligibility and surveillance decisions.