Cardiac Screening in Athletes: Current Status and Future Challenges

Pre-participation screening (PPS) is a primary-prevention strategy used in competitive sports to identify athletes at risk for cardiac diseases that can present with malignant arrhythmias and sudden cardiac death (SCD). Although compelling evidence supports the ability of PPS to lower SCD rates among athletes, no universal protocol has been adopted. Over time, however, key elements have emerged as common denominators: medical history, physical examination, and a 12-lead electrocardiogram (ECG). Research on ECG interpretation continues to evolve in search of the most accurate criteria for detecting cardiac disease, yet significant challenges persist. A major difficulty is the overlap between physiological remodeling in well-trained hearts and early manifestations of cardiomyopathy. In addition, some subgroups (female athletes, master athletes, and pediatric athletes) remain underrepresented in current studies. To ensure broad and equitable implementation, PPS must be supported by public-health policies and recognized as cost-effective, with the expectation that early identification of at-risk individuals will ultimately reduce the burden of advanced treatments on healthcare systems. Achieving this goal requires improving the sensitivity and specificity of existing screening tools to minimize misdiagnosis and avoid unnecessary secondary investigations or unwarranted disqualification from competition. This review summarizes the current status of cardiac screening in athletes, highlights persistent challenges, and outlines future directions to enhance its effectiveness and long-term sustainability.