Is it ethically and medically correct to perform an electrocardiogram (ECG) on all athletes?

Performing an electrocardiogram is a fundamental part of an athlete’s pre-participation cardiovascular evaluation. The contribution of the ECG in detecting clinically silent conditions that may predispose athletes to sudden cardiac death is decisive, as it increases detection sensitivity to over 90%.

For this reason, countries such as Cyprus, Greece, Italy, and Israel have established mandatory ECG requirements through specific legislation for those participating in official sporting events.

Last year, similar legislation was passed in the state of Florida in the United States.

This sparked some reactions from experts to such an extent that an announcement was finally issued by the American College of Cardiology (ACC). This specific announcement is co-signed by some of the major names in Sports Cardiology in America.

According to this announcement, the widespread use of electrocardiograms (ECGs) for all athletes conceals several pitfalls. A primary concern is that mass ECG screening, especially when performed by unqualified individuals, leads to a significant financial burden on the national health system.

The reckless and unnecessary referral of athletes for further imaging examinations brings not only financial but also psychological costs, as well as social stigmatization.

Adolescents and young athletes may be excluded from their teams and lose their scholarships, while their medical records are tarnished, causing serious repercussions for future employment and medical insurance.

According to the specific announcement, it appears more beneficial for public health to equip all sports venues with automated external defibrillators (AEDs) rather than performing ECGs on all athletes.

Regarding our country, the healthcare infrastructure is better and access to specialists is clearly easier compared to America. This potentially allows for the widespread performance of ECGs on athletes. However, the continuous education of doctors and their specialization in interpreting the athlete’s ECG is essential, so that the actual benefit to public health outweighs the financial, social, and psychological costs.

Reference:
JACC Journals, 13 February 2026
Authors: Jonathan H. Kim, Aaron L. Baggish, Doriane Coleman, Elizabeth H.
Dineen, Kimberly G. Harmon, Rachel Lampert, Benjamin D. Levine, and Matthew W.
Martinez
Opposing Legislative Mandates for ECG Screening in Competitive Athletes: A
Report of the American College of Cardiology Solution Set Oversight Committee

Bradycardia in athletes: The result of training or a genetic cause

Endurance athletes often exhibit low resting heart rates as a result of excessive training.

However, according to a recent study published in Circulation there seems to be a genetic predisposition to prominent bradycardia.

The study, which included 465 endurance athletes, supports the concept that some athletes are not only trained to have low heart rates but are also genetically predisposed to them.

This research raises the possibility that being born with a genetic substrate of lower heart rate increases the likelihood of better athletic performance, without any risk of cardiovascular events.

Reference:
Circulation. Originally Published 18 December 2025
Bradycardia in Athletes: Prevalence, Mechanisms, and Risks
https://doi.org/10.1161/CIRCULATIONAHA.125.076170

Exercise after myocardial infarction (practical advice)

1. Start slowly and progress gradually:

• Begin with low-intensity activities (e.g., short walks, light stretching).
• Follow cardiac rehab guidelines (typically starting with 5–10 min sessions, gradually increasing).
• Avoid sudden, intense exertion (e.g., heavy lifting, sprinting).

2. Choose safe and effective exercises:

• Walking (most recommended, start with 5–10 min, 2–3x/day).
• Stationary cycling (low impact, controlled intensity).
• Light resistance training (after clearance, using light weights or bands).
• Avoid isometric exercises (e.g., heavy weightlifting, push-ups).

3. Monitor Intensity (Use the “Talk Test” or Heart Rate):

• Exercise at a level where you can talk comfortably (no breathlessness).
• Target 50–70% of max heart rate (as advised by your doctor).

4. Stop immediately if you experience:

• Chest pain/discomfort.
• Severe shortness of breath.
• Dizziness or palpitations.

5. Warm-Up & Cool Down:

• Spend 5–10 min warming up (gentle walking/stretching).
• Cool down to prevent sudden blood pressure drops.

6. Stay Consistent but Listen to Your Body:

• Aim for 150 min/week of moderate activity (as tolerated).
• Rest if fatigued, exercise should not cause exhaustion.

7. Avoid Extreme Conditions:

• Exercise in moderate temperatures (avoid extreme cold/heat).
• Stay hydrated but avoid excessive fluid intake before exercise.

8. Follow Medical Advice:

• Attend cardiac rehabilitation if available.
• Consult your doctor before starting any new exercise.

Sudden cardiac arrest in marathons

The popularity of endurance training and long-distance running races is rapidly growing. This is clearly evident in a recently published study which demonstrated that more than 29 million people in the US completed in marathons and half-marathons from 2010 to 2023.

The incidence of sudden cardiac arrest was relatively unchanged over 2 decades, according to the researchers. The incidence rate was 0.54 per 100,000 participants in 2000-2009 compared with 0.6 per 100,000 participants in 2010-2023. According to the researchers, the incidence rate of sudden cardiac death declined from 0.39 per 100,000 participants in 2000-2009 to 0.2 per 100,000 participants in 2010-2023. It is assumed that this reflects the effectiveness of properly designed emergency response plans that provide prompt resuscitation and defibrillation.

Sudden cardiac arrest during races was more common in men compared to women (1.12 per 100,000 vs. 0.19 per 100,000) and also more possible to occur in marathon races compared to half-marathons (1.04 per 100,000 vs. 0.47 per 100,000).

Coronary artery disease appears as the most common etiology (nearly 50%), while a significant proportion (40%) was labeled as unexplained. Interestingly, hypertrophic cardiomyopathy was the cause in only 7%.

The findings of the study show that:

1. The possibility of sudden cardiac arrest in marathons is relatively small, but non-negligible.
2. It is imperative in such races to have a structured emergency response plan.
3. A high clinical suspicion is required when managing master endurance athletes. Early identification of subclinical coronary artery disease and initiation of statins may significantly reduce the incidence of adverse events.

Reference:
Kim JH, et al. JAMA. 2025;doi:10.1001/jama.2025.3026.

Clinical considerations in the cardiac evaluation of athletes

Pre-participation screening of athletes has been regulated as a fundamental principal, at least in most developed countries.

It is anticipated to identify structural or electrical abnormalities of the heart that may increase the risk of individuals that participate in competitive sports.

However, the decision of disqualification of athletes needs to be cautiously considered. It is imperative to be viewed beyond the scope of the science of medicine.

Several ethical and legal issues need to be cautiously addressed. The social, psychological and financial implications of disqualifying young athletes should not be neglected.

Any (adult) athlete should be free to decide after detailed explanation of the underlying diagnosis and potential risk.

These main principles are outlined in the very recent scientific statement published by the American College of Cardiology.

Reference:
https://www.ahajournals.org/doi/10.1161/CIR.0000000000001297

The effect of physical activity on life expectancy

The World Health Organization recommends at least 150 minutes of exercise per week.

Higher physical activity levels are expected to increase life expectancy, according to a recently published study.

According to a predictive model analysis, the researchers found that the most active portion of the investigated cohort could live an extra 5.3 years.

For the least active portion of the population there is still optimism, since an extra hour of walk could provide 6.3 hours of additional life expectancy.

The study clearly demonstrates that systematic physical activity is the safest investment for our health.

Reference:
Veerman L, Tarp J, Wijaya R, et al.
Physical activity and life expectancy: a life-table analysis
British Journal of Sports Medicine Published Online First: 14 November 2024

Bradycardia among endurance athletes: what is the risk of pacemaker implantation?

Resting bradycardia (low heart rate) is well known to be associated with exercise training, especially in endurance sports. It is supposed to be part of adaptive mechanisms that occur in the heart in order to be able to cope the burden of excessive exercise.

In a recent study, which included Swedish long-distance skiers this notion is questioned. It is proclaimed that a relatively increased risk of clinically significant bradycardia (sick sinus syndrome) along with the need for pacemaker implantation was found among athletes, particularly in the best-performing males.

Of course, the study once again demonstrates the overall benefits acquired from exercise, since the athletes still exhibited a lower overall mortality risk, and pacemaker implantation did not adversely affect their survival.

Reference:
Circulation
Long-Term Incidence of Bradycardia and Pacemaker Implantations Among Cross-Country Skiers: A
Cohort Study
Circulation 2024 Aug 05;[EPub Ahead of Print], N Svedberg, J Sundström, S James, U Hållmarker, K
Hambraeus, K Andersen

Which type of exercise may improve your cardiovascular risk?

In adults with overweight or obesity, aerobic exercise alone or a combined resistance plus aerobic exercise program leads to improvements in composite cardiovascular disease (CVD) risk profiles at one year, according to a study recently published in the European Heart Journal.

The study randomly assigned 406 adults (aged 35 to 70 years) with overweight or obesity and elevated blood pressure to

1. resistance exercise (102 participants)
2. aerobic exercise (101 participants)
3. combined resistance plus aerobic exercise (101 participants)
4. or a no-exercise control (102 participants)

Interventions lasted one hour, three times per week, for one year.

The researchers found that at one year, there were declines in the composite Z-score, indicating improved CVD risk profile, in the aerobic (mean difference, −0.15) and combination (mean difference, −0.16) groups. However, no improvement was seen in the resistance group (mean difference, −0.02).

Reference:
Aerobic, resistance, or combined exercise training and cardiovascular risk profile in overweight or obese
adults: the CardioRACE trial
European Heart Journal
Published: 17 January 2024