Prevention of sudden cardiac death in athletes: balancing safety, sustainability, and access to cardiovascular screening

Sudden cardiac death (SCD) in athletes remains a major clinical and public health concern, raising complex questions regarding the optimal balance between safety, sustainability, and equitable access to cardiovascular screening. Two contrasting paradigms are currently adopted worldwide: the mandatory and standardized Italian model and the voluntary, history-based approach predominantly used in the United States. The Italian system, which includes routine electrocardiography and exercise testing, has been associated with a marked reduction in SCD incidence but is burdened by high costs, false-positive findings, and organizational challenges. Conversely, the US model limits resource utilization but is associated with higher mortality rates and significant inequalities in access to preventive care. Using competitive basketball as a representative high-risk sport model, this narrative review summarizes the principal cardiac conditions associated with SCD. It discusses the strengths and limitations of existing screening strategies. We propose a hybrid, risk-based screening approach that integrates targeted diagnostic testing with continuous clinical surveillance, emergency preparedness, and structured education programs. Attention is given to the role of physiotherapists and allied health professionals as daily clinical observers within multidisciplinary teams. A multidimensional preventive strategy—combining selective screening, professional training, emergency action planning, and shared decision-making—may represent a sustainable and ethically sound model for further reducing SCD among athletes while preserving the right to sport.