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Aims: Differentiation of left ventricular (LV) hypertrophy in healthy athletes from pathological LV hypertrophy in heart disease is often difficult. We explored whether extended echocardiographic measurements such as E/e' and global longitudinal strain (GLS) distinguish physiologic from maladaptive hypertrophy in hypertrophic cardiomyopathy, excessively trained athletes' hearts and normal hearts., Methods: Seventy-eight professional athletes (cyclists n = 37, soccer players n = 29, handball players n = 21) were compared with patients (n = 88) with pathological LV hypertrophy (hypertrophic obstructive cardiomyopathy (HOCM, n = 17), hypertensive heart disease (HHD, n = 36), severe aortic valve stenosis (AVS, n = 35) and with sedentary healthy individuals as controls (n = 37)., Results: LV ejection fraction (LVEF) was ≥50% in all patients, athletes (median age 26 years, all male) and the controls (97% male, median age 32 years). LV mass index (LVMI) and septal wall thickness was in normal range in controls, but elevated in cyclists and patients with pathological hypertrophy (p < 0.001 for both). E/e' was elevated in all patients with maladaptive hypertrophy but normal in controls and athletes (p < 0.001 vs. pathological hypertrophy). Furthermore GLS was reduced in patients with pathological hypertrophy compared with athletes and controls (for both p < 0.001). In subjects with septal wall thickness >11 mm, GLS (≥-18%) has a specificity of 79% to distinguish between physiological and pathological hypertrophy., Conclusion: GLS and E/e' are reliable parameters unlike left ventricular mass or LV ejection fraction to distinguish pathological and physiological hypertrophy., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: L.L. received speaker honoraria from Medtronic and ReCor Medical, outside the submitted work. M.B. reports support from Abbott, Amgen, Astra-Zeneca, Bayer, Boehringer-Ingelheim, Medtronic, Novartis, Recor, Servier, and Vifor outside the submitted work. All other authors have declared no conflict of interest. S.E. received speakers or consultant honorarium and/or travel support from Medtronic, Recor, Bayer, Daiichi Sankyo, Böhringer Ingelheim, Novartis, AstraZeneca, Akcea Therapeutics and Bristol-Myers Squibb-Pfizer., (© 2022 Published by Elsevier B.V.)