Athlete pre-participation screening: what the exam looks for

A 17-year-old basketball player comes to the appointment with the club form in hand. He needs a stamp to start the season. He answers that everything is fine, that he has never fainted and that no one in his family has a heart problem. The blood pressure is normal, the heart has no audible murmur in the noisy room, and the form is almost ready.

The question that changes this appointment is simple: what exactly is this exam looking for? Pre-participation evaluation does not exist to certify that someone "can play sports" in a generic way. It looks for a specific group of diseases, rare and often silent, that can cause sudden death during exertion. Knowing which ones they are defines the questions, the physical examination and the choice of tests.

This text organizes the reasoning behind the evaluation: what the targets are, what the history, the physical examination and the electrocardiogram add, how the performance of each tool was measured and where screening fails, from the adolescent to the middle-aged runner.

Key points

• The major societies support cardiovascular screening before sports, but the best method in the young athlete remains under debate (Pelliccia, 2021).
• In the young, the causes of sudden death are cardiomyopathies, coronary anomalies and electrical diseases; after age 35, coronary disease predominates (Peterson, 2021; Pelliccia, 2021).
• In a prospective study, the 14-point questionnaire detected 18.8 out of every 100 athletes with disease, and the ECG, 87.5 out of every 100 (Williams, 2019).
• The Italian program found risk diseases in 69 of 22,324 children, most of them from age 12 onward (Sarto, 2023).
• In middle-aged runners, the screening protocols missed all three serious conditions found (Laily, 2024).
• A normal exam reduces the risk, but the athlete needs to know which symptoms to report afterward.

Summary

• What the evaluation looks for
• Who dies suddenly in sports
• History and physical examination
• The electrocardiogram in screening
• What screening programs find
• The middle-aged athlete: another target, other limits
• The limits of screening and what to tell the athlete
• How NEXO helps train this reasoning
• Frequently asked questions
• Take-home messages

What the evaluation looks for

The European sports cardiology guideline sums up the goal: to detect diseases associated with sudden death, which is the main cause of sport-related death in athletes (Pelliccia, 2021). Screening is supported by all major medical societies, but the best way to do it in athletes under 35 remains controversial, and the data for older athletes are limited.

The same guideline notes that the screening strategy must fit the population and the highest-risk diseases (Pelliccia, 2021). In the young, the target is a set of structural and electrical diseases: cardiomyopathies, channelopathies, coronary anomalies and acquired diseases such as myocarditis. Above age 35, atherosclerotic coronary disease accounts for more than 80 out of every 100 sudden deaths, and the athletes at highest risk are those with little or no history of systematic training.

This point changes the appointment. The evaluation of the teenager who plays basketball and that of the 48-year-old executive who decided to run a marathon have different targets, and copying the same form for both is the first reasoning error. The right question is which disease is being looked for, and not merely whether the athlete "is fit", reasoning similar to what is used in aviation cardiology.

Who dies suddenly in sports

The American prospective surveillance study gathered 331 confirmed episodes of sudden cardiac arrest or sudden death in competitive athletes over four years (Peterson, 2021). The mean age was 16.7 years, and most cases occurred in men, in high school athletes and during exercise, which concentrated 74.0 out of every 100 events (Peterson, 2021).

The most common causes were hypertrophic cardiomyopathy, in 20.6 per 100 episodes, idiopathic left ventricular hypertrophy, in 13.4, coronary anomalies, in 12.0, and sudden death with a negative autopsy, in 9.6 per 100 (Peterson, 2021). Coronary anomalies were more frequent in younger athletes, and cardiomyopathies accounted for almost half of the cases among college and professional players.

Risk varied widely between groups. Black Division I college basketball players had the highest annual incidence, of one event per 2087 athlete-years (Peterson, 2021). The authors note that coronary anomalies usually leave the ECG normal, but can present with chest pain or syncope during exertion, symptoms that make it necessary to rule out this cause.

In Italy, the Veneto registry followed children aged 8 to 15 for ten years (Graziano, 2024). The incidence of cardiac arrest or sudden death was 0.2 per 100,000 per year between ages 8 and 11 and 1.3 per 100,000 per year between ages 12 and 15 (Graziano, 2024). No athlete died of structural disease that screening could have identified, and the cause remained unexplained in four of the six athletes.

History and physical examination

The clinical history: what to ask

The history is the cheapest part of the evaluation and the easiest to do badly. The European document for pediatric athletes advises asking about cardiovascular symptoms with and without exertion: chest pain, shortness of breath out of proportion to exercise, palpitations and syncope (Pieles, 2026).

The family history should look for early-onset cardiovascular disease in first- or second-degree relatives: hereditary cardiomyopathies, arrhythmic syndromes, ischemic disease, aortic dissection, connective tissue diseases, arrhythmias or exertional syncope and sudden death before age 40 (Pieles, 2026). Common conditions, such as asthma, should also be noted because their symptoms overlap with those of heart disease.

Syncope during exertion deserves special attention. Fainting after finishing the run usually has a vasovagal cause; fainting in the middle of exertion, without warning, points to a cardiac cause until proven otherwise. The reasoning is close to what is used in syncope in the emergency department.

The problem with the history is its performance. The European guideline notes that several studies have documented low sensitivity and a high rate of positive responses on pre-participation questionnaires (Pelliccia, 2021). The teenager wants to play, the chest pain became "tiredness" and the family sometimes does not know the cause of the uncle's death. In para-athletes, the tendency to underreport health problems is even more marked, which requires a conversation adapted to the type of disability (Pinheiro, 2024).

The targeted physical examination

The physical examination looks for signs of some target diseases: murmurs that suggest outflow tract obstruction or valvular disease, a difference in pulses between arms and legs that suggests coarctation of the aorta, raised blood pressure and stigmata of connective tissue diseases, such as Marfan syndrome.

The murmur of obstructive hypertrophic cardiomyopathy increases when venous return decreases, for example when moving from a squatting position to standing. Auscultating only with the athlete lying down, in a noisy room, greatly reduces the chance of hearing it. Most hypertrophic cardiomyopathies, however, are nonobstructive at rest and produce no murmur at all.

In the American prospective study with high school athletes, the physical examination was abnormal in 356 of the 3620 evaluated, almost always without corresponding disease (Williams, 2019). This is the picture of a test with many false positives: each finding leads to an echocardiogram, and the vast majority of echocardiograms are normal. The risk of starting cascades of care exists in any screening strategy and must be part of the calculation.

The electrocardiogram in screening

The ECG is at the center of the debate. The European guideline states that, when experienced physicians use modern interpretation criteria for athletes, the ECG outperforms history and physical examination on every performance measure (Pelliccia, 2021). Echocardiography can find other structural diseases, but the evidence is insufficient to recommend it as a routine exam.

The Williams study compared the two strategies in the same athletes (Williams, 2019). Among 3620 adolescents, 16 had conditions associated with sudden death. The 14-point American Heart Association questionnaire had a sensitivity of 18.8 per 100, a specificity of 68.0 per 100 and a positive predictive value of 0.3 per 100 (Williams, 2019). The ECG interpreted by the Seattle criteria had a sensitivity of 87.5, a specificity of 97.5 and a positive predictive value of 13.6 per 100 (Williams, 2019).

A meta-analysis of studies published between 2015 and 2020 gathered 28,011 athletes aged 10 to 35 (Goff, 2023). The association between history and physical examination and the detection of conditions linked to sudden death was not statistically significant. For the ECG, the odds ratio was 148.

Tool	Sensitivity	Specificity	Positive predictive value	Source
AHA 14-point questionnaire	Low	Moderate	Very low	Williams, 2019
ECG with Seattle criteria	High	High	Low, but much higher than the questionnaire	Williams, 2019
Routine echocardiogram	Insufficient evidence for screening	Insufficient evidence	Insufficient evidence	Pelliccia, 2021
Exercise stress test in asymptomatic people over 35	Low positive predictive value	Many false positives	Low	Pelliccia, 2021

These numbers illustrate the logic of sensitivity, specificity and predictive values. Even the best test has a low positive predictive value when the disease is rare: of every seven abnormal ECGs, about one corresponds to real disease. Interpretation by someone who knows the adaptations of the athlete's heart is what separates a good screening program from a referral factory.

Why the athlete's ECG requires a trained reader

Intense training remodels the heart. Sinus bradycardia, first-degree atrioventricular block, early repolarization and isolated increased QRS voltage are common findings in athletes and generally reflect adaptation (Pieles, 2026). Other findings, such as T-wave inversion in lateral leads or ST-segment depression, call for investigation because they may be the first sign of cardiomyopathy.

The European document for pediatric athletes adds that the ECG of children and adolescents has its own patterns and proposes definitions of normal, borderline and abnormal findings for those under 16 (Pieles, 2026). In the absence of symptoms and of a relevant family history, several of these patterns require no investigation. Close reading of the tracing is the subject of the text on the athlete's ECG in this series.

The point for screening is that the same ECG can yield much or little depending on who interprets it. Older criteria, created for the general population, classified many tracings of healthy athletes as abnormal. Modern criteria reduced false positives without losing sensitivity, and the European guideline makes the good performance of the ECG conditional on experienced physicians using these criteria (Pelliccia, 2021).

What screening programs find

The Italian program is the longest and best documented. Over 11 years, 22,324 children aged 7 to 18 underwent 65,397 annual assessments with history, physical examination, resting ECG and exercise stress test (Sarto, 2023). Conditions at risk were identified in 69 children, among congenital heart diseases, channelopathies, cardiomyopathies and non-ischemic ventricular scar with arrhythmias.

Two details of this study matter for practice. Most diagnoses, 91 per 100, occurred from age 12 onward, and 64 per 100 emerged at a re-evaluation, not at the first visit (Sarto, 2023). Each diagnosis required an estimated expenditure of 73,312 euros on average. During a follow-up of 7.5 years on average, one child with a normal screening had a recovered cardiac arrest during sport (Sarto, 2023).

Pádua's study, with 25,251 young athletes aged 8 to 15, found 26 new diagnoses, with a higher yield from age 12 onward (Graziano, 2024). Two athletes with a negative screening had an unexplained cardiac arrest or sudden death during follow-up. Based on these data, the European document for pediatric athletes recommends history, physical examination and a 12-lead ECG starting at age 12 at the latest (Pieles, 2026).

In the United States, practice varies. In a survey of physicians at major university conferences, 45 of 65 responded; all took a history and performed a physical examination, and 58 in 100 also included the ECG for all athletes (Miars, 2018). For male basketball players, inclusion of the ECG rose to 71 in 100 schools (Miars, 2018). Among the physicians who had designed the protocol without considering the epidemiology of sudden death, most said they would not change their practice even in the face of current data. The finding shows that the choice of protocol also depends on resources, habit and institutional culture, beyond the evidence. For those working in a service without easy access to an ECG read by a specialist, a well-taken history and physical examination remain the starting point, as long as their limits are known and explained to the athlete and the family.

The middle-aged athlete: another target, other limits

After age 35, coronary disease becomes the main target (Pelliccia, 2021). The European guideline recommends estimating cardiovascular risk with scores such as SCORE and considering evaluation before sport in those with a higher probability of disease. Routine exercise testing in asymptomatic adults has low positive predictive value and many false positives, and is reserved for those with symptoms or high risk.

A Dutch study tested these rules in 25 men aged 35 to 50 who were preparing for their first marathon (Laily, 2024). Screening by the American College of Sports Medicine classified all of them as not needing medical clearance; screening by the European society classified two as high risk. The complete evaluation, with echocardiogram, cardiopulmonary exercise testing and magnetic resonance imaging, found three serious conditions that required restriction: aortic aneurysm, hypertrophic cardiomyopathy and myocardial fibrosis after myocarditis.

The American screening let all three through, and the European one marked only one of these three men as high risk, due to dyslipidemia and not to the cardiomyopathy (Laily, 2024). The study is small and does not change recommendations on its own, but it shows that questionnaires and scores let structural disease slip through. The tension between investigating more and avoiding excess is the same one discussed in pretest probability by Bayesian reasoning.

The limits of screening and what to tell the athlete

Every screening program lets some cases through. Some sudden deaths occur with a structurally normal heart, with no detectable abnormality before the event (Peterson, 2021). Coronary anomalies usually leave the ECG normal. And diseases such as myocarditis can appear after a clean evaluation.

The European document for pediatric athletes recommends informing athletes and parents about the limitations of screening and advising them to report any future symptom (Pieles, 2026). This conversation is part of the evaluation, not a footnote warning. The clearance stamp can create a false sense of security that delays seeking help when exertional syncope appears.

The other half of prevention is outside the office. Screening reduces the chance of an event, and the emergency response at the sports venue, with immediate resuscitation and an accessible defibrillator, changes the outcome when the event happens. In the American series, 158 of the 331 athletes survived the cardiac arrest (Peterson, 2021). The principle of prioritizing resuscitation also appears in rare situations, such as lightning injuries.

It is also worth remembering the bias of judging screening by its result. When an evaluated athlete dies, the tendency is to conclude that the evaluation was poorly done, even if it followed the recommendations. Separating the quality of the decision from the outcome, as discussed in retrospective and outcome bias, helps evaluate programs fairly.

Back to the basketball player

The adolescent in the opening scene belongs to one of the groups with the highest incidence described in American surveillance (Peterson, 2021). The consultation changes when you ask specifically about chest pain and fainting during training, and not "whether everything is fine". It also changes when auscultation is done standing and squatting, when the femoral pulses are palpated and when the family is asked about sudden death in relatives under 40 (Pieles, 2026).

If the service uses an ECG, it must be read with criteria for athletes. If the ECG shows lateral T-wave inversion, the next step is targeted investigation, not clearance. If everything comes back normal, the certificate is issued together with clear guidance: syncope or chest pain during exertion means stopping and seeking evaluation. This safety net, with time used as a tool, follows the logic of waiting with a safety net.

Populations with their own needs

Para-athletes have health problems linked to the type of disability and to the sport, and they often face barriers to accessing care (Pinheiro, 2024). The consensus statement on periodic assessment of para-athletes recommends reviewing the health history, adapting the examination to the demands of the sport and to the disability, and using the consultation for preventive education. Periodic assessment helps offset the tendency to under-report problems.

Children under 12 are another special group. Screening yield is lower in this age range, and events are rarer (Graziano, 2024). The European document acknowledges that a single echocardiogram can help identify structural disease invisible on ECG, provided the structure for it exists (Pieles, 2026).

How NEXO helps train this reasoning

In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues, and you propose the diagnosis by looking for the ICD-10 code.

The limits on using the game are described on the NEXO Economy page. If you research the teaching of clinical reasoning, the page for Researcher explains how to get in touch. Professionals who write or review cases find information under Curator and Creators, and institutions can learn about the proposal on the partnerships page. Reading each clue as a test and knowing the Canadian Syncope Risk Score complete this training.

Frequently asked questions

What does pre-participation evaluation look for?

Cardiovascular diseases associated with sudden death during exertion: cardiomyopathies, channelopathies, coronary anomalies and, after age 35, coronary disease (Pelliccia, 2021).

Are the questionnaire and physical examination enough?

They perform poorly. In the prospective study with adolescents, the 14-point questionnaire detected 18.8 per 100 athletes with disease, versus 87.5 per 100 for the ECG (Williams, 2019).

Should everyone have an echocardiogram?

The European guideline considers the evidence insufficient for routine echocardiography in screening (Pelliccia, 2021). It is used when the history, examination or ECG show an abnormality.

From what age should an ECG be done?

The European document for pediatric athletes recommends starting at age 12 at the latest, when screening yield increases (Pieles, 2026; Sarto, 2023).

Does a 45-year-old amateur runner need an exercise stress test?

It depends on the risk. Routine testing in asymptomatic people has low positive predictive value and is reserved for those with symptoms or high risk (Pelliccia, 2021).

Does a normal screening guarantee safety?

It reduces the risk, but cases with normal screening have been described (Sarto, 2023). The athlete must know how to report new symptoms (Pieles, 2026).

Take-home messages

• Pre-participation evaluation looks for specific diseases, and the target changes with age.
• In young people, cardiomyopathies, coronary anomalies and electrical diseases lead the causes; after age 35, coronary disease.
• Syncope during exertion points to a cardiac cause until proven otherwise.
• An ECG interpreted with criteria for athletes outperforms history and physical examination, but has limited positive predictive value.
• Many diagnoses appear from age 12 onward and on reassessments.
• In middle-aged adults, questionnaires and scores miss structural disease.
• Informing about the limits of screening and ensuring on-site resuscitation complete prevention.

Play the case of the day on NEXO.

References

1. Pelliccia A, Sharma S, Gati S, et al. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J. 2021. PMID 32860412. DOI 10.1093/eurheartj/ehaa605.
2. Peterson DF, Kucera K, Thomas LC, et al. Aetiology and incidence of sudden cardiac arrest and death in young competitive athletes in the USA: a 4-year prospective study. Br J Sports Med. 2021. PMID 33184114. DOI 10.1136/bjsports-2020-102666.
3. Graziano F, Schiavon M, Cipriani A, et al. Causes of sudden cardiac arrest and death and the diagnostic yield of sport preparticipation screening in children. Br J Sports Med. 2024. PMID 38233088. DOI 10.1136/bjsports-2023-107357.
4. Sarto P, Zorzi A, Merlo L, et al. Value of screening for the risk of sudden cardiac death in young competitive athletes. Eur Heart J. 2023. PMID 36760222. DOI 10.1093/eurheartj/ehad017.
5. Williams EA, Pelto HF, Toresdahl BG, et al. Performance of the American Heart Association (AHA) 14-Point Evaluation Versus Electrocardiography for the Cardiovascular Screening of High School Athletes: A Prospective Study. J Am Heart Assoc. 2019. PMID 31286819. DOI 10.1161/JAHA.119.012235.
6. Goff NK, Hutchinson A, Koek W, et al. Meta-analysis on the Effectiveness of ECG Screening for Conditions Related to Sudden Cardiac Death in Young Athletes. Clin Pediatr (Phila). 2023. PMID 36797841. DOI 10.1177/00099228231152857.
7. Laily I, Wiggers TGH, van Steijn N, et al. Pre-Participation Screenings Frequently Miss Occult Cardiovascular Conditions in Apparently Healthy Male Middle-Aged First-Time Marathon Runners. Cardiology. 2024. PMID 38325343. DOI 10.1159/000536553.
8. Miars CW, Stamatis A, Morgan GB, et al. Cardiovascular Screening Practices and Attitudes From the NCAA Autonomous "Power" 5 Conferences. Sports Health. 2018. PMID 29792780. DOI 10.1177/1941738118775039.
9. Pieles GE, Cavarretta E, Orchard JJ, et al. Cardiac evaluation of paediatric athletes. Eur Heart J. 2026. PMID 41967042. DOI 10.1093/eurheartj/ehag188.
10. Pinheiro L, Verhagen E, Ocarino J, et al. Periodic health evaluation in Para athletes: a position statement based on expert consensus. BMJ Open Sport Exerc Med. 2024. PMID 39411023. DOI 10.1136/bmjsem-2024-001946.