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How to conduct pre-participation screening in athletes

Erik Ekker Solberg, EACPR Sports Cardiology Section, answers key questions

In the endeavours to optimize effects of sports participation and training, unfortunate side-effects should be minimized. Indeed, the devastating impact of cardiac arrest (CA) or sudden death (SD) in athletes has shocked societies and sports spectators all over the world.  Preventive measures, specifically pre-participation screening have been advocated by the European Society of Cardioloy (ESC) and have subsequently been implemented in some sporting communities. The EACPR Sports Cardiology section answers below our key questions on pre-participation screening.

Sudden Cardiac Death and Resuscitation

Key questions: Pre-participation screening

1. Why perfom pre-participation screening?
2. What are the benefits?  
3. How to do it?  
4. Related educational resources 
5. Key library – Which position papers are recommended?

1. Why perform pre-participation screening?

Considerable interest has been raised on the role of pre-participation screening (PPS) for early identification of cardiovascular diseases responsible for cardiac arrests (CA) and sudden deaths (SD) related to sports. Today, available evidence suggests that screening may save lives. Heterogeneity does exist, however, regarding the medical cardiac supervision of competitive athletes, although several nations require medical clearance before sports participation. The large sports organisations [Fédération Internationale de Football Association (FIFA), the Union of European Football Associations (UEFA) (mandated) and the International Olympic Committee (IOC)] (recommended)] support PPS.  Additionally, examination of the heart (PPS) is a natural element of the so-called periodic health evaluation. Furthermore, PPS will provide vital information of cardiac adaption to sports, the athlete’s heart.

2. What are the benefits?

In a large study, Italian investigators demonstrated a 89 % decrease in SD in sports during a 26 years screening period (3). The well-documented increased risk of SD during sports compared to at rest was practically levelled during this long study period, because those individuals prone to CA/SD in sports were disqualified from competitive sports. The report, thus, constitutes a proof-of-principle of screening. A proof-of-practice of screening, however, is not established in the same manner. Only a few countries have outcome data of screening. Also, the result of screening will depend on feasibility, cardiac expertise, priority of resources and experience in the field. Remember, screening does not prevent totally, but reduces CA/SD in sports. For example, the standard screening procedure may often miss ion channel disease and coronary artery anomalies.

3. How to do it?

PPS should be aimed at detecting the most common causes of sports-related SD. In younger athletes (<35 years), a broad spectrum of cardiovascular causes of SD including congenital and inherited disorders has been reported. In master athletes (> 35 years), atherosclerotic coronary artery disease is by far the most common cause of cardiac events. The focus, thus, differ between these two groups.

a. Young athletes
The wide spectrum of underlying cardiac diseases can best be covered by PPS including a family and personal history, a clinical examination and a 12-lead electrocardiogram (ECG) at rest. It has been shown that inclusion of an ECG is able to detect more underlying problems. Although it constitutes an added cost, it is still more cost-effective than screening without an ECG.

b. Master athletes
The methods of how middle-aged and older individuals should be evaluated before engaging in regular physical activity are controversial. On practical grounds, such evaluation should vary according to the individual’s cardiac risk profile and the intended level of physical activity. To pre-select high-risk subjects, self- assessment of their risk factors and habitual physical activity level are recommended for screening of large populations (2). When more elderly athletes, including those with known diseases, are advised to exercise, the issue of screening gains further relevance.

Recommended screening program
The recommended PPS program consists of four parts (1):
I. Family history [specific questions]
II. The athlete’s history regarding sports [specific questions]
III. Simple medical examination: blood pressure measurement, auscultation, palpitation of large arteries
IV. Resting 12-lead ECG

A flow chart of the screening process, from the screening to the final results of eligibility for sports or further management of positive findings according to protocol, is shown in this figure (1).


flow chart taken from "Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol." Corrado D et al.; Eur Heart J 2005.



The athletic evaluation should be performed periodically, has been suggested every second year, and more often in younger, growing athletes than in older. The conducting physicians need specific medical training and skills, also knowledge of ethnic variation of the findings, to identify reliably clinical symptoms and signs associated with cardiovascular diseases responsible for exercise-related CA/SD. They should be aware of the pitfalls of screening, especially false positive findings, and consult normal reference values for athletes.

4. Related educational resources

Discover the ESC eLearning Platform on Prevention with courses in Sports Cardiology including pre-participation screening.

Access the video and slides presentation of the session: "Pre-participation screening of asymptomatic athletes does reduce their risk of sudden cardiac death : Electrocardiographic screening does reduce their risk for sudden cardiac death." held at the ESC Congress 2013." (Pro/Contra).

5.  Key library – Which position papers are recommended?

A comprehensive list of literature, dealing with various aspects of pre-participation screening, is found on the website of the EACPR Sports Cardiology Section.

In particular, we recommend:

Screening of young athletes <35 years old
1) Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol.
Corrado D, Pelliccia A, Bjørnstad H, Vanhees L, Biffi A, Børjesson M, Panhuyzen-Goedkoop N, Deligiannis A, Solberg E, Dugmore D, Melwig KP, D Assanelli D, P Delise, F van-Buuren, A Anastasakis, H Heidbuchel, E Hoffmann, R Fagard, SG Priori, C Basso, E Arbustini, C Blostrom-Lundquist, W McKenna, G Thiene.
Eur Heart J 2005; 26: 516-524.

Evaluation of master athletes >35-40 years old
2) Cardiovascular evaluation of middle-aged/senior individuals engaged in leisure-time sport activities: position stand from the sections of exercise physiology and sports cardiology of the European Association of Cardiovascular Prevention and Rehabilitation.  
Borjesson M, Urhausen A, Kouidi E, Dugmore D, Sharma S, Halle M, Heidbuchel,H., Bjornstad,H.H., Gielen,S., Mezzani,A., Corrado,D., Pelliccia,A., Vanhees,L.
Eur J Cardiovasc Prev Rehabil 2011; 18:446-58.

Effetcs of screening
3) Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program
Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G.
JAMA 2006; 296:1593-601.

Evaluation of athletes’ ECG
4) Recommendations for interpretation of 12-lead electrocardiogram in the athlete.  
Corrado,D.; Pelliccia,A.; Heidbuchel,H.; Sharma,S.; Link,M.; Basso,C.; Biffi,A.; Buja,G.; Delise,P.; Gussac,I.; Anastasakis,A.; Borjesson,M.; Bjornstad,H.H.; Carre,F.; Deligiannis,A.; Dugmore,D.; Fagard,R.; Hoogsteen,J.; Mellwig,K.P.; Panhuyzen-Goedkoop,N.; Solberg,E.; Vanhees,L.; Drezner,J.; Estes,N.A.,III; Iliceto,S.; Maron,B.J.; Peidro,R.; Schwartz,P.J.; Stein,R.; Thiene,G.; Zeppilli,P.; McKenna,W.J.
Eur Heart J, 2010;31:243-59.