The Impact of Body Surface Area on Morpho-Functional and Cardiometabolic Parameters in a Large Cohort of Olympic Athletes: Distinct Bodies, Distinct Physiology

<b>Background:</b> Body surface area is a key determinant of cardiac morphology and function, but it is often underestimated in the interpretation of athlete's cardiac phenotypes. <b>Aims:</b> This study aimed to assess the role of anthropometric characteristics and whether particularly high vs. low body surface area (BSA) is associated with distinct morpho-functional and cardiometabolic features in elite athletes. <b>Methods:</b> We retrospectively included 2518 Olympic athletes. All underwent a pre-participation screening, including physical examination, ECG, blood analysis, echocardiography, and cardiopulmonary exercise testing. Participants were grouped by sex-specific BSA percentiles: Group A (<5th percentile), Group B (25th-75th), and Group C (>95th percentile). Functional, echocardiographic, and cardio-metabolic parameters were compared among groups. <b>Results:</b> In male athletes, Group C showed higher resting systolic blood pressure (123.8 ± 10.4 mmHg) than Group B (117.4 ± 9.6, <i>p</i> < 0.0001) and Group A (110.4 ± 13, <i>p</i> < 0.0001), and a higher prevalence of dyslipidemia (31.7% vs. 11.1% in Group B and 4% in Group A, <i>p</i> = 0.031). Despite greater LVEDD (59 ± 3 mm in Group C vs. 55 ± 2.9 in B and 51.1 ± 3.1 in A, <i>p</i> < 0.0001) and LV mass (<i>p</i> < 0.0001), functional performance was lower in Group C, with VO₂ max/kg of 35.2 ± 13.2 mL/min/kg vs. 44 ± 7.1 in B, and 47.8 ± 7.3 in A (<i>p</i> < 0.0001). Similar trends were observed in females for morpho-functional parameters, though lipid profiles did not significantly differ among groups (<i>p</i> > 0.05). <b>Conclusions:</b> Anthropometric traits significantly influence the cardiovascular and metabolic phenotype of elite athletes. Our findings support the integration of anthropometric profiling into the routine cardiovascular assessment of athletes, especially those at the extremes of body size, to better interpret physiological adaptations and risk profiles.