Purpose of review Excessive trabeculation attracting a diagnosis of left ventricular noncompaction cardiomyopathy (LVNC) has been reported in ostensibly healthy athletes. This review aims to explain why this occurs and whether this represents a spectrum of athletic physiological remodelling or unmasking of occult cardiomyopathy. Recent findings Genetic studies have yet to identify a dominant mutation associated with the LVNC phenotype and reported gene mutations overlap with many distinct cardiomyopathies and ion channel disorders, implying that the phenotype is shared across different genetic conditions. Large contemporary cohort studies indicate that current LVNC imaging criteria are oversensitive and not predictive of adverse clinical outcomes. Summary The majority of excessive LV trabeculation, as assessed by current quantification methods, is not due to cardiomyopathy but forms part of the normal continuum in health with potential contributions from cardiac remodelling processes. The study of rare, severe LVNC phenotypes may yield insights into an underlying molecular pathogenesis but in the absence of a universally accepted definition, contamination with aetiologically distinct conditions expressing a similar phenotype will remain an issue. Automated, objective quantification of trabeculation will help to define the normal distribution using big data without the constraint of wide interobserver variation.

Purpose of review: Pre-participation cardiovascular evaluation with electrocardiography is normal practice for most sporting bodies. Awareness about sudden cardiac death in athletes and recognizing how screening can help identify vulnerable athletes have empowered different sporting disciplines to invest in the wellbeing of their athletes.Recent findings: Discerning physiological electrical alterations due to athletic training from those representing cardiac pathology may be challenging. The mode of investigation of affected athletes is dependent on the electrical anomaly and the disease(s) in question.Summary: This review will highlight specific pathological ECG patterns that warrant assessment and surveillance, together with an in-depth review of the recommended algorithm for evaluation.

Athletes commonly exhibit a series of electrical, structural, and functional physiological changes which may overlap with cardiac pathology. The last two decades have witnessed a progressive improvement in understanding what can be considered benign for athletes and what may be deemed as potentially pathological and require further investigations. However, diagnostic uncertainties in the cardiac assessment of athletes are often encountered. In particular, the clinical significance of some electrocardiogram (ECG) findings may be uncertain. While uncommon and suggestive of an underlying cardiac condition, they may be identified among healthy athletes without additional pathological findings to support a unifying clinical diagnosis. This creates significant dilemmas for clinicians charged with determining sports eligibility and those who have the responsibility to help athletes in the decision-making process regarding future competitive sports participation. Current guidelines, recommendations, and position papers provide a roadmap for the differential diagnosis between ‘athlete's heart’ and cardiac disease. However, managing ECG findings of uncertain clinical significance, especially when initial diagnostic evaluation reveals no supportive signs of pathology, has received comparatively less attention, in particular, the type of cardiac investigations, the extent of diagnostic work-up and the need for follow-up require clarification. This document aims to provide guidance based on published evidence and expert opinions to assist in the clinical decision-making regarding ECG anomalies that are common sources of uncertainty when managing asymptomatic athletes.

Paediatric athletes are not simply ‘mini adults’. Most existing recommendations for cardiac screening in paediatric athletes are primarily based on evidence in adults and are designed for adult athletes. Paediatric-specific recommendations are needed due to the specifics of cardiac physiology, maturation and growth, age-related disease expression, modified diagnostic pathways, training adaptations, and to address relevant ethical considerations. This clinical consensus document from the European Association of Preventive Cardiology (EAPC) of the ESC and the Association for European Paediatric and Congenital Cardiology (AEPC) introduces specific advice for paediatric athletes for the first time, based on expert consensus, and where available, data from paediatric athlete populations. Members of the writing group voted anonymously on key advice statements, with ≥80% agreement required for consensus. All advice in this document applies to paediatric athletes aged <16 years, including those under 12 years of age. This document advises that cardiac screening of paediatric athletes with personal and family medical history, physical examination and 12-lead resting electrocardiogram (ECG) should be performed and should start no later than the age of 12 years. Implementing a screening programme requires ensuring the availability of necessary healthcare resources. One transthoracic echocardiogram may be appropriate to identify high-risk structural cardiac diseases not identifiable on ECG, provided appropriate infrastructure for baseline diagnostic assessments is in place. This document also includes suggested definitions of normal, borderline and abnormal ECG findings in paediatric athletes. Detailed advice is provided for further evaluation if suspicious findings are identified on initial tests. This document highlights that further research is required to optimise screening strategies, accurately assess and quantify the risk of sudden cardiac death and provide evidence-based eligibility recommendations for paediatric athletes with cardiac disease. It is also noted that increased opportunities for paediatric sports cardiology training are required to provide adequate medical care for the paediatric athlete population.

Sudden cardiac death (SCD) in young individuals is often unexpected, provoking substantial emotional stress for family and friends of the deceased. Cardiac screening may identify individuals who harbour disorders linked to SCD. The feasibility and diagnostic yield of a nationwide cardiac screening program in adolescents has never been explored. All individuals eligible for cardiac screening (15-year old students) were systematically invited to enrol. Students were provided with a health questionnaire. ECGs were acquired at school. A physician led consultation was carried out on site. Participants with an abnormal screen were then referred for secondary evaluation to the nation's tertiary centre. Feasibility criteria included a) participation rate >60%, b) adherence to secondary evaluation >80% and c) cost per individual screened equating to <€100. The diagnostic yield was also evaluated. At the end of enrolment, 2708 students gave consent (mean 15 years, 50.4% male), equating to 67.9% of the eligible cohort. 109 participant (4.0%) were referred for further evaluation. An abnormal ECG was the commonest reason for referral (3.7%). Fifteen individuals (0.6%) were diagnosed with a cardiac condition. Nine (0.3%) had a condition linked to SCD (n=1 LQTS, n=1 HCM, n=5 WPW, n=2 coronary anomalies). The yield was similar in athletes and non-athletes (p=0.324). The cost per cardiac individual screened equated to €51.15. A nationwide systematic cardiac screening program for adolescent athletes and non-athletes is feasible and cost-efficient, provided that responsible centres have the appropriate infrastructure.

Cardiovascular magnetic resonance imaging (MRI) is an advanced cardiac imaging modality that is often required when evaluating athletic individuals. Unrestricted imaging planes, excellent spatial resolution, and a lack of ionising radiation are some of the benefits of this modality. Cardiac MRI has been established as the gold standard imaging modality for morphological assessment, volumetric analysis, and tissue characterisation. Cardiac MRI without any doubt is an excellent diagnostic tool when evaluating athletes with symptoms or those individuals exhibiting equivocal findings at screening. It is also useful for athletes who fall within the grey zone and is especially important among athletes with a suspected or confirmed diagnosis. Cardiac MRI plays a strategic role when adopting a shared decision-making model in athletes with heart disease, tailoring and personalising medical care to the condition and the athlete’s wishes. The aim of this review is to provide a comprehensive yet practical overview of the role of cardiac MRI when evaluating athletes in clinic.