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 United States 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.

Emery MS, Kovacs RJ. Sudden cardiac death in athletes. JACC Heart Fail 2018;6:30-40. DOI: https://doi.org/10.1016/j.jchf.2017.07.014

Corrado D, Basso C, Rizzoli G, et al. Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol 2003;42:1959-63. DOI: https://doi.org/10.1016/j.jacc.2003.03.002

Maron BJ, Haas TS, Ahluwalia A, et al. Demographics and epidemiology of sudden deaths in young competitive athletes: from the United States National Registry. Am J Med 2016;129:1170-7. DOI: https://doi.org/10.1016/j.amjmed.2016.02.031

Harmon KG, Asid IM, Maleszewski JJ, et al. Incidence, cause, and comparative frequency of sudden cardiac death in NCAA athletes: a decade in review. Circulation 2015;132:10-9. DOI: https://doi.org/10.1161/CIRCULATIONAHA.115.015431

Marian AJ, Braunwald E. Hypertrophic cardiomyopathy: genetics, pathogenesis, clinical manifestations, diagnosis, and therapy. Circ Res 2017;121:749-70. DOI: https://doi.org/10.1161/CIRCRESAHA.117.311059

Christian S, Cirino A, Hansen B, et al. Diagnostic validity and clinical utility of genetic testing for hypertrophic cardiomyopathy: a systematic review and meta-analysis. Open Heart 2022;9:e001815. DOI: https://doi.org/10.1136/openhrt-2021-001815

Arbustini E, Protonotarios A, Gimeno JR, et al. 2023 ESC guidelines for the management of cardiomyopathies. Eur Heart J 2023;44:3503-626. DOI: https://doi.org/10.1093/eurheartj/ehad194

Ommen SR, Mital S, Burke M, et al. 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 2020;76:e159-240. DOI: https://doi.org/10.1016/j.jacc.2020.08.045

Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339:364-9. DOI: https://doi.org/10.1056/NEJM199808063390602

Krahn AD, Wilde AAM, Calkins H, et al. Arrhythmogenic right ventricular cardiomyopathy. JACC Clin Electrophysiol 2022;8:533-53. DOI: https://doi.org/10.1016/j.jacep.2021.12.002

James CA, Bhonsale A, Tichnell C, et al. Exercise increases age-related penetrance and arrhythmic risk in ARVC-associated desmosomal mutation carriers. J Am Coll Cardiol 2013;62:1290-7. DOI: https://doi.org/10.1016/j.jacc.2013.06.033

Corrado D, Perazzolo Marra M, Zorzi A, et al. Diagnosis of arrhythmogenic cardiomyopathy: the Padua criteria. Int J Cardiol 2020;319:106-14. DOI: https://doi.org/10.1016/j.ijcard.2020.06.005

Mast TP, James CA, Clakins H, et al. Evaluation of structural progression in arrhythmogenic right ventricular dysplasia/cardiomyopathy. JAMA Cardiol 2017;2:293-302. DOI: https://doi.org/10.1001/jamacardio.2016.5035

Saberniak J, Hasselberg NE, Borgquist R, et al. Vigorous physical activity impairs myocardial function in patients with arrhythmogenic right ventricular cardiomyopathy. Eur J Heart Fail 2014;16:1337-44. DOI: https://doi.org/10.1002/ejhf.181

Stȩpień-Wojno M, Ponińska J, Biernacka EK, et al. A recurrent exertional syncope and sudden cardiac arrest in a young athlete with known pathogenic p.ARG420GLN variant in the RYR2 gene. Diagnostics 2020;10:435. DOI: https://doi.org/10.3390/diagnostics10070435

Tobert KE, Bos JM, Garmany R, Ackerman MJ. Return-to-play for athletes with long QT syndrome or genetic heart diseases predisposing to sudden death. J Am Coll Cardiol 2021;78:594-604. DOI: https://doi.org/10.1016/j.jacc.2021.04.026

Zorzi A, Vessella T, De Lazzari M, et al. Screening young athletes for diseases at risk of sudden cardiac death: role of stress testing for ventricular arrhythmias. Eur J Prev Cardiol 2020;27:311-20. DOI: https://doi.org/10.1177/2047487319890973

Gentile F, Castiglione V, de Caterina R. Coronary artery anomalies. Circulation 2021;144:983-96. DOI: https://doi.org/10.1161/CIRCULATIONAHA.121.055347

Gräni C, Kaufmann PA, Windecker S, Buechel RR. Diagnosis and management of anomalous coronary arteries with a malignant course. Interv Cardiol Rev 2019;14:83-7. DOI: https://doi.org/10.15420/icr.2019.1.1

Xie Z, Zou J, Zhu H, Bu H. Case report: anomalous origin of the right coronary artery from the left sinus of valsalva with aortic dissection. Front Cardiovasc Med 2022;9:900803. DOI: https://doi.org/10.3389/fcvm.2022.900803

Angelini P. Is echocardiography adequate to identify the severity of anomalous coronary arteries? JACC Cardiovasc Imaging 2016;9:898-9. DOI: https://doi.org/10.1016/j.jcmg.2015.12.010

Tso JV, Cantu SM, Kim JH. Case series of coronary artery anomalies in athletes: challenges in clinical management and sports eligibility. JACC Case Rep 2022;4:1074-9. DOI: https://doi.org/10.1016/j.jaccas.2022.06.014

Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to Preparticipation Screening for Cardiovascular Abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation 2007;115:1643-55. DOI: https://doi.org/10.1161/CIRCULATIONAHA.107.181423

Fritsch P, Ehringer-Schetitska D, Dalla Pozza R, et al. Cardiovascular pre-participation screening in young athletes: recommendations of the Association of European Paediatric Cardiology. Cardiol Young 2017;27:311-20. DOI: https://doi.org/10.1017/S1047951117001305

Ebadi AA. Student athlete ECGs: case examples of normal and abnormal sport physical ECGs. Prog Pediatr Cardiol 2022;65:101519. DOI: https://doi.org/10.1016/j.ppedcard.2022.101519

Mitten MJ, Maron BJ, Zipes DP. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 15: legal aspects. J Am Coll Cardiol 2015;66:2447-50. DOI: https://doi.org/10.1016/j.jacc.2015.09.047

Anderson CL, Munawar S, Reilly L, et al. How functional genomics can keep pace with VUS identification. Front Cardiovasc Med 2022;9:900431. DOI: https://doi.org/10.3389/fcvm.2022.900431

Bourdon PC, Cardinale M, Murray A, et al. Monitoring athlete training loads: consensus statement. Int J Sports Physiol Perform 2017;12:S2161-70. DOI: https://doi.org/10.1123/IJSPP.2017-0208

West AS, Clubb J, Torres-Ronda L, et al. More than a metric. Int J Sports Med 2021;42:300-6. DOI: https://doi.org/10.1055/a-1268-8791

Bosch B, Mansell H. Interprofessional collaboration in health care: lessons to be learned from competitive sports. Can Pharm J 2015;148:176-9. DOI: https://doi.org/10.1177/1715163515588106

Casa DJ, Guskiewicz KM, Anderson SA, et al. National Athletic Trainers’ Association position statement: preventing sudden death in sports. J Athl Train 2012;47:96-118. DOI: https://doi.org/10.4085/1062-6050-47.1.96

Kerr ZY, Gildner P, Parker SK, et al. Sport culture and communication among middle school athletes, parents, and staff: a qualitative study. PLoS One 2023;18:e0282252. DOI: https://doi.org/10.1371/journal.pone.0282252

Madias C, Maron BJ, Alsheikh-Ali A, et al. Commotio cordis. Indian Pacing Electrophysiol J 2007;7:235-9.