Cardiac biomarkers in athletes and active individuals: a clinical review of exercise-induced elevations and...

Exercise-induced increases in cardiac biomarkers, especially natriuretic peptides (B-type Natriuretic Peptide (BNP)/N-terminal (NT)-proBNP) and high-sensitivity troponin (hs-cTn), make it more difficult to distinguish between myocardial disease and physiological adaptation in athletes. The pathophysiology, release kinetics, and diagnostic performance of established biomarkers (hs-cTnI, hs-cTnT, BNP, NT-proBNP) and emerging candidates (galectin-3, ST2, GDF-15, heart-type fatty acid-binding protein, cardiac myosin-binding protein-C) are examined in this review. The main limitations include the lack of athlete-specific reference ranges (74-96% of marathon runners exceed standard hs-cTn thresholds), small sample sizes (most n<100), short follow-up, and varied exercise protocols. The assessment of acute cardiac stress, the distinction between an athlete's heart and cardiomyopathy, and the choice to return to play after myocarditis continue to be the principal clinical uses. Without thorough confirmation, claims like artificial intelligence-powered multi-omics, tailored molecular exercise prescription, and real-time monitoring remain theoretical. Sport-specific 99th percentiles, large prospective cohorts with 5-10-year follow-up, standardized methodologies, and verified point-of-care testing are all necessary for future priority. Until then, prolonged increases (>72 hours) or symptomatic presentations warrant further research, whereas exercise-induced biomarker elevations in asymptomatic athletes should be considered mostly benign and temporary.