From Sudden Cardiac Death Prevention to Performance Optimization: A Conceptual Framework for Cardiovascular...

Cardiovascular pre-participation evaluation in elite athletes primarily aims to identify cardiovascular conditions associated with sudden cardiac death. Current international recommendations emphasize comprehensive medical history, physical examination, and resting 12-lead electrocardiography (ECG), with additional investigations guided by clini-cal findings and individual risk. However, advances in sports cardiology, cardiovascular imaging, and exercise physiology provide opportunities to integrate cardiovascular risk assessment with physiological performance evaluation. This article proposes a concep-tual, hypothesis-generating framework integrating structural, electrical, and functional cardiovascular assessment in elite athletes. The framework consists of 3 sequential components: comprehensive clinical assessment with resting ECG; transthoracic echo-cardiography for structural evaluation and longitudinal reference; and cardiopulmonary exercise testing (CPET) as an optional complementary investigation. Cardiopulmonary exercise testing may provide information on maximal oxygen uptake, ventilatory thresh-olds, oxygen pulse, ventilatory efficiency, heart rate recovery, and exercise-induced arrhythmias, potentially supporting individualized training prescription and longitudinal physiological monitoring. Cardiac magnetic resonance and coronary computed tomog-raphy angiography (CCTA) may be considered selectively when clinically indicated. A one-time CCTA strategy during an athlete's career is proposed as a research hypothesis requiring prospective assessment of clinical utility and cost-effectiveness. Importantly, CPET and CCTA are not proposed as universal screening requirements. This framework is intended to complement, rather than replace, current evidence-based international recommendations. As the proposed model is based on available literature and expert opinion and has not undergone prospective clinical validation, future multicenter stud-ies are required to determine whether integrated cardiovascular assessment improves risk stratification, athlete safety, clinical decision-making, performance monitoring, and cost-effectiveness.