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Left ventricular (LV) remodeling in competitive athletes is a complex phenomenon, in which genetic and environmental determinants are implicated. In recent years, several investigations have demonstrated an association between LV remodeling and the angiotensin-converting enzyme (ACE I/D) and/or angiotensinogen (AGT M/T) polymorphism, with athletes with the DD and/or TT alleles, respectively, showing the greatest increase in LV mass, independent from other determinants. However, the impact of the known genetic determinants on LV remodeling is at present incomplete, and comparative assessment of the genetic and environmental factors, such as the type and intensity of athletic conditioning, suggests that genetic determinants may explain up to one-quarter of the overall variability of LV dimensions. A better understanding of genetic factors may provide an insight into the pathways producing physiological cardiac remodeling, and will be important in understanding the intrinsic nature and clinical significance of the extreme LV morphologic changes observed in highly trained and elite athletes.