Athlete's Heart in Women's Contact Sports: Echocardiographic and Strain-Based Insights From Elite Rugby Players

Background: Athlete's heart encompasses cardiac adaptations to long-term intensive training. Although male-dominated sports have been widely studied, limited data exist on structural and functional cardiac remodeling in female contact-sport athletes. This study aimed to evaluate cardiac changes in elite female rugby players using conventional and strain echocardiography. Methods: This cross-sectional study included 66 elite female rugby players and 50 sedentary controls. Anthropometric measurements and transthoracic echocardiographic assessments, including speckle tracking-derived global longitudinal strain (GLS), were performed. Linear, multivariable, and partial correlation analyses evaluated associations between GLS, active playing years (APY), and body mass index (BMI). Results: Compared to controls, athletes exhibited increased ventricular diameters, wall thicknesses, and left atrial size, with preserved left ventricular ejection fraction (LVEF). GLS values were significantly lower in rugby players (p < 0.001), though within normal limits. APY and BMI both showed significant inverse correlations with GLS (r = -0.456 and -0.370, respectively). In multivariable analysis, APY (beta = -0.392, p = 0.001) and BMI (beta = -0.225, p = 0.013) independently predicted GLS. Partial correlation confirmed the independent association of APY with GLS (r = -0.412, p = 0.001). GLS showed strong discriminative performance for >= 5 years of play (AUC = 0.816) and moderate performance for BMI >= 24.13 (AUC = 0.666). Conclusion: Elite female rugby athletes demonstrate physiological cardiac remodeling, including reduced GLS associated with training duration and BMI. These findings highlight the need for sex- and sport-specific echocardiographic reference values and further longitudinal research to clarify long-term clinical implications.