Pre-participation cardiovascular evaluation in Italian elite athletes (2023-2026): diagnostic yield, accuracy, and...

Elite athletes represent a unique population within competitive sports. Despite repeated cardiovascular screening during their careers, they may harbour clinically silent but potentially serious cardiovascular diseases. Therefore, cardiovascular evaluation in elite athletes may require a sensitive and comprehensive diagnostic approach.

We analyzed 1505 elite athletes, undergoing comprehensive PPS including resting ECG, transthoracic echocardiography (TTE), and cardiopulmonary exercise testing (CPET). Major cardiovascular abnormalities (MCA) and cardiomyopathies were established according to the final clinical diagnosis, served as the reference standard. Sensitivity, specificity, positive and negative predictive values (NPV), and ROC analyses were assessed for ECG alone and for ECG combined with CPET or TTE.

MCA were identified in 17 athletes (1.13%), including 7 cardiomyopathies (0.46%) and 6 channelopathies (0.40%). CPET identified additional cardiomyopathies through exercise-induced arrhythmias, including cases not detected by resting ECG, whereas TTE identified structural and coronary abnormalities not evident on ECG. Resting ECG showed a sensitivity of 58.8% and specificity of 94.0% for MCA, with a NPV 99.5%. The addition of CPET increased sensitivity to 82.4%, although specificity decreased to 82.2%. ECG + TTE achieved a sensitivity of 76.5% and specificity of 91.5%. ROC analysis showed AUCs of 0.76 for ECG, 0.82 for ECG + CPET, and 0.84 for ECG + TTE for MCA.

In this highly selected cohort of elite athletes, integrating ECG, CPET, and TTE provided complementary diagnostic information and increased the detection of MCA compared with resting ECG alone. These findings support the feasibility of a comprehensive cardiovascular evaluation model in highly selected athletes evaluated within specialized sports cardiology settings.