01Role and principlesWho benefits and the main preventive aims.
Exercise benefits cardiovascular health, but intense activity can trigger events in susceptible disease. Screening aims to find the small high-risk group without medicalising normal adaptation or offering false reassurance.
Assessment considers dynamic versus static load, competitive level, environment, medication/device issues and the athlete's values. Return to play after myocarditis, ACS, ablation or surgery needs condition-specific reassessment.
Key points
- Pre-participation assessment starts with personal symptoms, family history, examination and—especially for competitive/professional athletes—a resting 12-lead ECG interpreted using athlete-specific criteria.
- Exertional syncope, chest pain, disproportionate dyspnoea or abrupt palpitations is a stop-and-investigate signal.
- Ask about sudden unexplained death, cardiomyopathy, channelopathy and premature coronary disease in relatives.
- Training can cause sinus bradycardia, increased voltages and early repolarisation; physiological patterns must be separated from pathological T-wave inversion, pre-excitation, long QT or Brugada patterns.
- Exercise testing should reproduce the sport's workload; stopping at 85% of age-predicted maximum may miss exercise-induced arrhythmia.
- Eligibility is disease-, phenotype-, sport- and intensity-specific and should use shared decision-making rather than blanket exclusion.
- Every sports setting should have a rehearsed emergency action plan with an immediately accessible AED.
02Assessment and patient selectionRisk features, eligibility and important cautions.
Syncope during exercise is more concerning than a typical post-exertional vasovagal episode and warrants urgent cardiac evaluation.
Exercise-related pressure, unusual breathlessness or reduced performance may represent coronary disease or anomalous coronary anatomy.
Sudden rapid palpitations, presyncope or seizure-like collapse, especially during exertion or emotion.
Sudden unexplained death before 50, inherited cardiomyopathy/channelopathy, unexplained drowning or multiple premature cardiac events.
Pathological murmur, unequal pulses/BP, Marfan features, hypertension or signs of cardiomyopathy/heart failure.
03Baseline assessmentMeasurements that guide the plan and track progress.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Resting 12-lead ECGFirst step - Why
- Screen electrical disease and cardiomyopathy clues in competitive/professional assessment.
- Interpretation and limitations
- Use international athlete ECG criteria and consider ethnicity, age and training; investigate pathological patterns rather than all voltage changes.
- 02
Transthoracic echocardiography - Why
- Assess murmur, abnormal ECG, symptoms or family history.
- Interpretation and limitations
- Distinguish balanced athletic remodelling from unexplained hypertrophy, dilatation, dysfunction or valve/aortic disease.
- 03
Maximal exercise testing - Why
- Reproduce symptoms and assess BP, ischaemia and exercise-induced arrhythmia.
- Interpretation and limitations
- Use a sport-specific or high-workload protocol where safe; monitor recovery as well as exercise.
- 04
Ambulatory ECG during training - Why
- Capture intermittent palpitations and define ectopy response to exercise.
- Interpretation and limitations
- Complex, multifocal or exercise-augmented ventricular ectopy warrants structural and inherited-disease evaluation.
- 05
CMR or coronary imaging - Why
- Resolve suspected cardiomyopathy, myocarditis, scar, aortopathy or anomalous coronary origin.
- Interpretation and limitations
- Choose the test to answer the specific suspected substrate; do not use blanket CT screening.
04InterventionsLifestyle, treatment and escalation options.
01FirstPre-participation evaluationFirst stepCompetitive/professional sport or a participant with symptoms, disease or family risk.+
- 1Define the sport, intensity, training volume, performance-enhancing substances and personal goals.
- 2Take symptom and three-generation family history; examine BP, pulses, heart and syndromic features.
- 3Obtain a resting ECG for competitive/professional assessment and interpret with athlete-specific criteria.
- 4Clear low-risk findings or route any red flag to targeted testing before high-intensity participation.
02NextAbnormal screen or known CVDSymptoms, abnormal ECG/examination, family history or established cardiac diagnosis.+
- 1Pause high-intensity competition when a dangerous substrate is plausible; explain that ordinary light activity may still be appropriate.
- 2Use echo, maximal exercise testing, training-session monitoring and CMR/coronary imaging as indicated.
- 3Risk-stratify the specific condition and sport with a sports cardiology/inherited-cardiac team.
- 4Agree participation limits, treatment, follow-up and a shared emergency plan, documenting uncertainty.
03EscalationCollapse on the field of playEscalationUnresponsive athlete with absent or abnormal breathing.+
- 1Recognise presumed cardiac arrest, call 999 and summon the field-of-play medical team and AED.
- 2Start high-quality CPR immediately and attach/switch on the AED as soon as it arrives.
- 3Deliver indicated shocks with minimal compression interruption; do not prioritise moving the athlete over CPR/defibrillation.
- 4Transfer to hospital after initial resuscitation and investigate the athlete and, when indicated, first-degree relatives.
05Targets, monitoring and follow-upResponse, safety and longer-term review.
- Review new exertional symptoms or family diagnoses immediately rather than waiting for the next scheduled screen.
- For known CVD, repeat ECG, imaging, exercise and rhythm assessment at disease-specific intervals and after treatment changes.
- Monitor blood pressure both at rest and exercise when hypertension or aortopathy is relevant.
- Review supplements, stimulants, performance-enhancing drugs and QT-prolonging or dehydrating medicines.
- Rehearse the venue emergency action plan and record the AED location, immediate accessibility, readiness and maintenance checks.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
During versus after exercise
Syncope during exertion is a cardiac red flag; abrupt standing still after exertion more often causes reflex hypotension, but history must be rigorous.
Athlete ECG needs context
Voltage criteria alone commonly reflect training, whereas lateral T-wave inversion or pathological Q waves require evaluation.
Match the workload
A submaximal treadmill may not reproduce an arrhythmia that appears only at the athlete's training intensity.
Shared decisions are not no-risk claims
Document residual uncertainty, warning symptoms and emergency planning when participation continues with disease.
AED proximity is measurable
A device locked remotely from the field undermines the emergency plan; immediate access and rehearsal matter.
07Common pitfallsFrequent interpretation and management errors.
- 01
Reassuring exertional syncope as a simple faint without cardiac investigation.
- 02
Calling normal athletic voltage hypertrophy cardiomyopathy without considering athlete criteria.
- 03
Ending exercise testing at 85% predicted heart rate when symptoms occur only at higher workload.
- 04
Using one universal restriction for all genotypes, phenotypes and sports.
- 05
Keeping the AED locked or too distant to permit rapid defibrillation.