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Regular intensive physical exertion results in physiological cardiac adaptations named athlete’s heart. Adaptations are functional and structural and depend on intensity and type of exercise, age, sex, body surface area, race and genetics. Functional adaptations are due to high parasympathetic (vagal) tone, which results in resting bradycardia. Frequent accompanying electrocardiographic changes include respiratory sinus arrhythmia, early repolarization pattern and atrioventricular conduction alterations in the form of first degree AV block and second degree AV block Mobitz type 1. Over a period of time, intensive exercise results in structural changes characterised by increased dimensions of all cardiac chambers and mild left ventricular hypertrophy. Structural adaptations are most frequently imaged with cardiac ultrasound. Isolated voltage criteria for left ventricular hypertrophy and incomplete right bundle branch block are common electrocardiographic manifestations of structural adaptations. Athlete’s heart may result in diagnostic overlap with pathological conditions, mainly cardiomyopathies, in which vigorous exercise is associated with an increased risk of adverse events including sudden cardiac death. A detailed knowledge about physiological adaptations is crucial for the proper differentiation between physiological and pathological remodelling.