Cardiac Prevention in Athletes: Traditional Screenings and Cardiac Ultrasound

When we engage in physical activity or sports, our heart must work harder, increasing its effort to pump more oxygen-rich blood to the muscles in motion.

Since the heart operates under greater strain during sports, proper prevention becomes even more crucial, especially when there is suspicion of underlying cardiac conditions that may pose a risk.

Major Cardiac Conditions

Some of the primary causes of serious cardiac events during sports activities include:

• Hypertrophic cardiomyopathy
• Various types of cardiac arrhythmias
• Coronary artery diseases (both congenital and acquired)
• Malfunctions of the heart valves

Certain conditions, such as coronary artery anomalies or arrhythmogenic right ventricular dysplasia, are congenital, meaning they are present from birth but may remain silent for years. They can suddenly manifest with severe consequences in adolescence or adulthood. Others, like hypertrophic cardiomyopathy, may develop over time.

In extreme cases—though fortunately rare—some of these conditions can lead to sudden cardiac death during sports activities, an outcome that could often be prevented through thorough heart screenings and proper medical evaluations.

Traditional cardiac check-ups include tests such as the sports electrocardiogram (ECG) and the stress test ECG.

The electrocardiogram (ECG) is a diagnostic test capable of analyzing the heart's rhythm and electrical activity. It is performed using an electrocardiograph, which records and graphically represents the electrical activity of the heart. It is an extremely useful tool for understanding the state of heart health and identifying any arrhythmias or signs of cardiomyopathies. The test is quick, painless, and non-invasive.

The stress test ECG, simply put, is the recording of an ECG during physical exertion, which can be performed using steps, a stationary bike, or a treadmill. During the test, blood pressure is also monitored.

The purpose of this test is to observe the response of the heart and circulatory system under physical stress, in order to detect possible ischemic alterations or cardiac rhythm abnormalities. It is useful for evaluating exercise tolerance, but it may not be sufficient to highlight alterations related to congenital coronary anomalies, which often do not cause changes in these screening tests.

These evaluations are designed to allow for the screening of large populations in a non-invasive manner while still being able to exclude major abnormalities. However, they have limited precision in identifying and detecting structural problems or conditions such as coronary anomalies, heart valve disorders, or myocardial thickening, which can only be identified using advanced imaging technologies.

In particular, congenital anomalies of the coronary arteries may go undetected in basic tests, making a more detailed approach necessary.

The echocardiogram, or echocardiography, is a non-invasive diagnostic test used to assess the functionality and structure of the heart. Ultrasound uses high-frequency sound waves, which are reflected by tissues such as the heart, based on the principle of echo.

Thanks to this property of ultrasound, it is able to create images of organs, even in motion, like the heart, showing its size, shape, and its ability to pump blood throughout the body.

It provides a detailed view of the heart’s structures, and due to its ability to visualize the heart in motion in real-time, it allows for the detection of:

• Thickening of the heart walls, characteristic of hypertrophic cardiomyopathy, one of the leading causes of sudden death in young athletes;
• Valve dysfunctions, such as insufficiencies or stenosis, which can compromise athletic performance and increase the risk of complications;
• Abnormalities of ventricular function, which cannot be detected through ECG or stress tests;
• Congenital heart abnormalities, including coronary anomalies originating from the aorta, one of the conditions associated with sudden death during exertion.

Performing a cardiac ultrasound provides a more comprehensive diagnosis, reaching where classic tests cannot.

Integrating traditional screening tests with an ultrasound is particularly recommended for athletes who present clinical situations of concern, such as:

• Family history: having a family history of heart diseases, such as sudden death or cardiomyopathies. Genetics plays a crucial role in cardiac risk and should not be underestimated;
• Suspicious symptoms: excessive fatigue, palpitations, chest pain, or fainting during physical activity. These signs could indicate underlying issues;
• Intensive sports: disciplines that involve high cardiovascular exertion, such as cycling, long-distance running, or competitive sports;
• Anomalies detected during traditional exams, such as a suspicious ECG or inconclusive stress test, which are better investigated further;
• Advanced age of the amateur athlete: sports after the age of 40 should be monitored, and it is particularly important to rule out coronary diseases or other acquired heart anomalies.

“It is important not to create alarm, but to educate the population to be more aware of heart health and cardiovascular prevention. We need to reach young people with educational moments even in school age to raise awareness on this topic and convey the message that prevention could save many lives,” says Dr. Lo Rito.

When you are an athlete, whether amateur or young, it is important to approach your discipline with relaxation and safety. When indicated, integrating preventive screenings with a heart ultrasound not only helps identify potential issues but also reduces the risk. Additionally, a heart ultrasound is useful for monitoring those who have already experienced some cardiac problems but still wish to pursue sports.

"Having heart problems doesn't always mean that sports have to be eliminated from your life. One can still be 'athletic' even with heart problems, as long as, under the guidance of a sports and cardiology medical professional, physical and sporting activities are adjusted to fit one's cardiac condition," concludes Lo Rito.