The athlete’s heart Towards tailored clinical decision-making on athlete screening

Athlete screening for high-risk cardiovascular conditions (HRCC) aims to prevent sudden cardiac arrest/death. It relies on expert opinions and data from young male athletes (≤35 years). Screening findings may mimic HRCC and need to be distinguished from exercise-induced cardiac remodeling (EICR). We investigated the available evidence on athlete screening and present new data on EICR.
Evidence
In our systematic review (82,417 competitive athletes, 22% females), we assessed the evidence of athlete screening as 'very low’ and identified 0.43% HRCC detection rate and 13% false positive rate. Comparing three sets of ECG criteria used in young athlete screening, we determined that they were also suitable for master athletes (>35 years).
Cardiac remodeling
Reviewing 29 articles (4,852 female athletes), EICR associated electrical features included left ventricular hypertrophy, J-point elevation and T-wave inversion. Morphological features comprised ventricular and left atrial volume increase. Comparing power-trained track cyclists to endurance-trained road cyclists, we noted lesser increase in ventricular and atrial volume increase but enlarged ventricular wall thickness and mass. In Olympic rowers, we observed that intensifying exercise volume induced further left-sided without right-sided EICR.
Conclusion
Evidence on athlete screening is insufficient, and HRCC prevalence very low. The dynamic changes in EICR are influenced by sex, sports type, and exercise volume, challenging to establish fixed metrics for defining 'normal'. To optimize the benefits of athlete screening, we suggest incorporating a pre-screening assessment to determine the HRCC probability and assess the appropriateness of screening. Additionally, we propose an HRCC risk assessment for clinical and eligibility decision-making.