The Use of Myocardial Work in Athletes: A Novel Approach to Assess Cardiac Adaptations and Differentiate Physiological Remodeling from Pathology

Myocardial work (MW), derived from non-invasive pressure–strain loop (PSL) analysis, has recently emerged as a promising echocardiographic index for assessing left ventricular performance. It integrates speckle-tracking echocardiography with estimated left ventricular pressure, providing a load-adjusted measure of myocardial performance. This technique addresses the limitations of traditional parameters such as global longitudinal strain (GLS) and ejection fraction (EF), particularly in populations exposed to dynamic loading conditions, such as athletes. Athletic training induces a spectrum of cardiac adaptations, collectively referred to as the “athlete’s heart,” which may mimic or mask pathological conditions. In this context, MW represents a valuable tool to differentiate physiological remodeling from early myocardial dysfunction or underlying cardiovascular disease (e.g., cardiomyopathies, myocarditis). The aim of this review is to explore the physiological rationale for using MW in athletes, evaluate its relationship with performance metrics (e.g., VO2max, lactate threshold), and discuss its potential, yet still emerging and not fully validated, role in informing training adaptation and detecting subclinical cardiac conditions. Additionally, we examine MW applications across different sport disciplines (strength, mixed-sport, and endurance), highlighting its role in individualized assessment and risk stratification. By synthesizing current evidence and outlining future research directions, this work emphasizes the potential of MW to become a standard component of cardiovascular evaluation in sports cardiology.