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Sports Cardiology & Preparticipation Screening

Learning Objectives

Core Knowledge & Clinical Reasoning

  • [ ] Apply the 2025 paradigm shift: shared decision-making replaces absolute disqualification for most conditions
  • [ ] Evaluate preparticipation screening history and exam findings to identify red flags
  • [ ] Analyze ECG findings to differentiate athlete's heart from pathology (HCM, ARVC, channelopathies)
  • [ ] Formulate condition-specific return-to-play recommendations based on current guidelines

Clinical Assessment

  • [ ] Perform comprehensive cardiovascular PPE including targeted history and focused exam
  • [ ] Interpret ECG in athletes using updated international criteria

Communication & Counseling

  • [ ] Lead shared decision-making discussions with athletes and families regarding participation risks
  • [ ] Discuss individual risk-benefit balance for athletes with cardiac conditions
  • [ ] Create documentation of informed consent for at-risk athletes choosing to participate

Systems-Based Practice

  • [ ] Coordinate with athletic trainers and schools regarding emergency action plans
  • [ ] Ensure availability of AEDs and trained personnel at sporting events

Key Guidelines

2025 AHA/ACC Scientific Statement: Clinical Considerations for Competitive Sports Participation with CV Abnormalities JACC. 2025;85(10):1059-1108

2024 HRS Expert Consensus: Arrhythmias in Athletes Heart Rhythm. 2024

Quick Reference: Sports Clearance Algorithm

2025 PARADIGM SHIFT

Old Approach

  • Binary disqualification
  • Physician-directed decisions
  • Conservative restrictions

New Approach

  • Shared decision-making is CENTRAL
  • Risk often LOWER than previously thought
  • Athletes may compete with many conditions if:
  • Fully informed of risks
  • Under expert surveillance
  • Appropriate monitoring in place

AHA 14-Element Screening (Current US Standard)

Personal History (7 Elements)

  1. Exertional chest pain/discomfort
  2. Unexplained syncope/near-syncope
  3. Excessive dyspnea/fatigue with exercise
  4. Prior heart murmur recognition
  5. Elevated blood pressure
  6. Prior restriction from sports
  7. Prior cardiac testing

Family History (3 Elements)

  1. Premature death (sudden/unexpected) <50 years
  2. Heart disease in relatives <50 years
  3. Specific knowledge of cardiomyopathy, LQTS, Marfan, arrhythmias

Physical Exam (4 Elements)

  1. Heart murmur (supine and standing)
  2. Femoral pulses (for coarctation)
  3. Marfan stigmata
  4. Blood pressure measurement

Note: ECG NOT routinely recommended in US (differs from European guidelines)

Condition-Specific Guidance (2025)

Hypertrophic Cardiomyopathy

  • May participate with expert counsel and surveillance
  • Shared decision-making required
  • Absolute disqualification is RARE

Long QT Syndrome

  • More permissive approach
  • Avoid triggers specific to genotype
  • Beta-blocker compliance essential

Arrhythmogenic Cardiomyopathy

  • Case-by-case evaluation
  • Generally more restrictive
  • Exercise may accelerate disease

Marfan Syndrome

  • Updated aortic dimension thresholds
  • Low-intensity sports often acceptable
  • Avoid collision/contact sports

Coronary Artery Anomalies (AAOCA)

  • See Topic 27 for details
  • AAORCA with negative stress: May participate (Class IIa)
  • AAOLCA: Restrict until repaired

Post-Ablation

  • Return after 1-4 weeks (depends on ablation type)
  • Exercise testing often recommended before return

With ICD

  • Competition with ICDs now "REASONABLE"
  • Previously more restricted
  • Requires informed consent, monitoring

Return-to-Play After Cardiac Conditions

Condition Minimum Restriction Requirements
Myocarditis 3-6 months Normal echo, Holter, stress test
MIS-C (cardiac involvement) 3-6 months Normal echo, ECG
Post-ablation 1-4 weeks Depends on complexity
Concussion with cardiac symptoms Individual assessment Cardiology clearance

2024 HRS Athletes & Arrhythmias

Key points: - First athlete-specific statement from HRS - Return-to-play guidance post-ablation - Updated ICD and exercise recommendations - Emphasizes multidisciplinary decision-making

Board Pearls

Pearl: Shared decision-making is NOW STANDARD

Absolute disqualification is rare; athletes may compete with many conditions

Pearl: ECG NOT routinely recommended in US screening

14-element history/exam approach is US standard (differs from European)

Pearl: Competition with ICDs is now "reasonable"

Major change from prior restrictive guidelines

Self-Assessment

Q1: A 16-year-old competitive swimmer with LQTS1 on nadolol wants to continue swimming. Parents ask if this is possible. What is the appropriate response?

Answer **Answer**: Swimming may be possible through shared decision-making **Rationale**: Per 2025 guidelines, shared decision-making is central. LQTS1 is triggered by swimming, but absolute disqualification is no longer standard. The athlete/family must be fully informed of risks, nadolol compliance is essential, and close surveillance is required. With these conditions, participation may be reasonable.

Q2: A 14-year-old with HCM (moderate LVH, no risk factors) wants to play basketball. What is the current guidance?

Answer **Answer**: May participate with expert counsel, comprehensive evaluation, and close surveillance **Rationale**: The 2025 guidelines state HCM patients "may participate with expert counsel and close surveillance." This requires comprehensive evaluation, full informed consent, discussion of SCD risk, and ongoing monitoring. Absolute disqualification is no longer routine.

References

  • 2025 AHA/ACC Sports Participation Statement. JACC. 2025;85:1059-1108
  • 2024 HRS Arrhythmias in Athletes Consensus