The benefits of regular and moderate exercise training on cardiovascular outcomes have been well established. In addition, strenuous exercise training leads to corollary cardiac structural and functional adaptations that are sport-specific and facilitate athletic performance. In this review, the normal physiologic and hemodynamic changes that occur during exercise and the subsequent differential exercise-induced cardiac remodeling patterns that develop will be discussed. Paradoxically, recent data have raised concern about the long-term impact of higher doses of physical activity and exercise on mortality and cardiovascular health outcomes. We will discuss important aspects of these controversial data and review the supporting evidence as well as the limitations of prior research. Specifically, we will address the association between high levels of exercise and relative reductions in overall mortality, increased risk of atrial fibrillation, arrhythmogenic cardiac remodeling, and accelerated coronary artery calcifications. For the practitioner, this review aims to detail these contemporary sports cardiology controversies and highlights the critical need to incorporate shared decision making with the athlete in dealing with the uncertainties that exist. Finally, we will discuss key "athlete-specific" variables that should be considered in the design of future important research in this arena.
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