INTRODUCTION: SUDDEN CARDIAC DEATH PREVENTION IN FOOTBALL
The unexpected death of Marc Vivien Foé on the field-of-play at the FIFA Confederations Cup 2003, was a devastating event. The imagen of the player dressed in the green jersey of the Cameroonian national team, carried lifeless out of the field-of-play remains engrave in our collective sports-medicine consciousness; we frequently see it – or use it – when addressing questions around Sudden Cardiac Death (SCD) in sports.
Indeed, the sudden death of a young and apparently healthy athlete is always a devastating event. It is frequently highlighted by the media, that draws the attention to the youth of this population and accounts for the causes of the tragedy, compelling to governments, medical societies and sport governing bodies to develop and implement effective preventive strategies. Such was the effect of the unexpected death of Marc Vivien Foé on the field-of-play at the FIFA Confederations Cup 2003, that led FIFA to support all efforts to prevent SCD in football players.
Professional football players are subject to intense cardiovascular demands and those with underlying cardiovascular conditions may be susceptible to adverse events during sports participation – including cardiac arrest (CA) and SCD. The prevention of such events requires appropriate management by expert’s sports cardiologist for risk mitigation and safe sports participation. Therefore, the cardiovascular screening of football players aimed to detect those with underlying cardiac conditions is, together with the appropriate management of players with cardiac pathology the most important tools for the primary prevention of SCD. This primary prevention together with the early recognition, early defibrillation and correct management of players that suffer a cardiac arrest in the field of play configure the key strategies in the prevention of SCD in football.
First implemented in the 2006 FIFA World Cup1 and FIFA Women’s World Cup 2007, the “pre-competition medical assessment” or PCMA developed by the FIFA Medical Assessment and Research Centre (F-MARC) has been already in use for twenty years. Beyond serving as preventive strategy for SCD of the individual players, FIFA PCMA has provided sports cardiologists and sports medicine physicians with a valuable amount of relevant data on the outcome of cardiac screening in football players around the world. This data has been instrumental to the understanding of athlete’s heart in football players and the differentiation between normal from abnormal findings in the interpretation of ECG and echocardiography in different subpopulations of players according with their sex, age and ethnicity.
PCMA has also served to identify the most prevalent cardiac pathologies in football players and to record the cardiac outcomes of players with cardiac abnormalities who continued playing football against expert advice. This evidence has contributed to refined expert sports cardiology recommendations and management plans, becoming more supportive for players with underlaying cardiac pathology. Competitive sports restrictions have been lifted for most conditions. Risk assessment, management and eligibility decisions have change dramatically from a binary yes/no and rather “paternalistic” approach to a more open, shared decisions-making process on the eligibility and management of players with cardiac pathology.
Considering all the above we can say that the mandatory cardiac screening of football players imposed by FIFA has been an important source that has contributed significantly to the advancement of sports Cardiology in the last two decades.
CARDIAC SCREENING AS PREVENTIVE STRATEGY FOR SUDDEN CARDIAC DEATH IN FOOTBALL
PCMA focused on the cardiovascular and the musculoskeletal system with the respective questions and examinations formulated by experts in the field1. The cardiovascular assessment involves a focused investigation of the player and its family medical history, a cardiac physical examination and a resting 12-lead ECG to be completed annually. An echocardiography is recommended at least once in a player’s early career to better detect structural disorders not routinely identified by ECG2, and is required for players participating in major tournaments (i.e. FIFA world cup). An exercise test is recommended for players over 35 year to screen for coronary artery disease (CAD), the main cause of SCD over this age and is an integral part of the PCMA of referees and assistant referees—independently of their age—since the 2010 FIFA World Cup and FIFA Women’s World Cup 2011, first international events in which referees completed their PCMA3,4.
As described by Dvorak et al1 ‘FIFA aimed to create a role model for the PCMA of international elite football players with maximum probability to identify risk factors... As the assessment was not intended as a screening tool for the general population, but for the specific examination of elite athletes at the largest sports event, additional investigations were included to achieve maximum probability of risk factor detection. Considering this, all consultants agreed on the inclusion of 2-dimensional transthoracic echocardiography…’.
It is difficult to evaluate the effectiveness of the PCMA in the prevention of SCD due to the lack of data regarding incidence of SCD in football before/after the implantation of PCMA despite the existing FIFA registry of SCD in football5. Autopsy-based studies in Turkey6 have shown an incidence of SCD in football of 0.41/100.000, affecting only male with average age 35.5±10.4 years. One third of SCD occurred in individuals age 30-39, although those 40–49-years have the highest age-specific mortality rate (0.67 per 100,000 population). None of the deaths occurred in elite footballers, 4.2% were non-elite competitive players, the remaining were all recreational players. The difference on incidence of SCD between elite/competitive/recreational was, according with the authors, mostly due to the comprehensive cardiac screening that elite and even amateur - although to a lower extent- undergo every year.
Similar type of study conducted in Spain during an 8-year period7, have shown that SCD in sports affect mostly recreational athletes (96%), mostly men (98.6%) being football with 18% of the cases, the second sport in incidence of SCD after cycling, even though only 9.5% of the population plays football. Most of the football players died before 35 years and the study showed that people younger than 35 years who play football are at higher risk of SCD than those of the same age who practice other sports.
A recent study8 of 15,127 athletes – not limited to football players – has demonstrated the importance of serial screenings for the identification of pathologies associated with SCD, with serial evaluation as opposed to a one-off evaluation increasing the diagnostic yield of cardiovascular disease at risk of sudden cardiac death by 3-fold.
These studies demonstrate not only the need for cardiovascular assessment of football players, including recreational footballers, from early age but also illustrates the importance of repeated screening for an effective prevention of SCD. Question remains on which should be the periodicity of cardiac screening. Evidence have shown that adverse cardiac events may occur in football player after 16-18 months of their cardiac assessment9,10; therefore, current recommendations of yearly screening may not be inappropriate, although a period between the assessment of 18-24 months may be reasonable if that increases the number of players screened.
Importantly, cardiac screening also detects cardiac conditions not immediately associated with SCD which appropriate management and preventive strategies may have high impact, i.e. hypertension, the most common cardiovascular condition found in athletes, leading cardiovascular risk factor (CVRF) with high morbimortality later in life. Screening is also an excellent opportunity for health education of footballers on red flag symptoms and preventive strategies for conditions at risk of SCD i.e. avoid training during a viral infection aimed to prevent development of myocarditis. Finally, as stated by Berge et al9 “it is important to remind athletes that a normal cardiac screening does not protect against all cardiac diseases. Timely reporting of symptoms is essential. The risk of false-negative screening results has been largely neglected”.
A. Value of History and Physical Examination in the Cardiac Screening of Football Players
The personal and family history of the players together with the physical examination remains an important part of the PCMA where red flags can help to identify players that may harbour an underlying cardiac pathology and being at risk of SCD. The history is assessed through a comprehensive questionnaire. Although FIFA states that it should be completed with a physician, a study found that 22% of Australian football players had completed the history on their own11.
Most relevant red flag symptoms: syncope, chest pain, palpitations, shortness of breath or severe dizziness specially occurred during exercise and other subtle symptoms such as change on performance with unexplained fatigue should be carefully interpreted. 72% of SCA victims were reported to have at least one cardiovascular symptom, on average 30 months before the event12. But symptoms may be very unspecific, underreported by experienced players while young adolescents may over report them, therefore physician supervision, experience and expertise in cardiovascular history taking is though paramount. In a study of over 26,000 individuals, Dhutia et al13 showed that 17.9% of athletes self-reported at least one positive symptom, figure that fell to just 1.6% following physician review.
A 2015 meta-analysis from Harmon et al14 investigating over 47,000 athletes found a pooled sensitivity of 20% to history. A recent study showed a diagnostic yield of history for diagnosis associated with SCD in football of 33%10.
The most relevant abnormalities in the physical examination of football players are the presence of heart murmurs, abnormal femoral pulses, abnormal blood pressure and Marfan syndrome stigmata. On the 2015 meta-analysis from Harmon et al14 the pooled sensitivity of physical examination to detect cardiac conditions associated with SCD was low, just 9% (3-24%) but had very high specificity: 97%. In the setting of football, the diagnostic yield of physical examination to detect cardiac pathology associated with SCD is found to be 17%10.
B. Role of ECG in the Cardiac Screening of Football Players
The inclusion of an ECG within preparticipation screening by the European Society of Cardiology (ESC) in 200515 has demonstrated to be an effective strategy to detect athletes with cardiovascular conditions, with a sensitivity of 94%14. Some of the challenges faced during the PCMA relates with the appropriate interpretation of the ECG findings in football players and the differences in the electrocardiographic manifestations of athletic remodeling between football players of different ages, sex and ethnicities.
Although underrepresented in most studies, black athletes seem to have an increased risk for adverse cardiac events during sports16 and those from west and middle African countries manifest significant changes on ECG and echocardiography17. As a result of these changes, they require a significant higher number of secondary investigations (i.e. cardiac MRI or CMR) to evaluate grey cases in whom findings overlap with those of cardiomyopathy17. Interestingly, a recent study including 6125 Brazilian football players18 have shown a low prevalence of abnormal ECGs (3%) for young footballers of mixed ethnicity (aged 15 to 25) with a very low prevalence of abnormal findings in the Brazilian black footballer which highlight that not only ethnicity but regional origin influence differences on the outcome of screening in football players.
The rate of false positive in the interpretation of the ECG of athletes has reduced significantly during the last 20 years thanks to the evolution of the criteria for ECG interpretation in athletes that has significantly improved the specificity of ECG screening. From the initial criteria from the ESC15 in 2005, to the last International Criteria for ECG interpretation in athletes19 published in 2017, which false positive/abnormal ECG rates ranged between 1.7% and 6.8%20–24 in different studies. In a study of over 11,000 adolescent football players, the false positive rate went from 12.9% using the 2010 ESC25 criteria to 1.5% using the latest International recommendations with a sensitivity for detecting serious conditions associated with SCD of 86%.
A new criteria for ECG interpretation in athletes is expected to be published during 2026 and although its bibliographic reference is not available at the time of writing this article, the interested reader will certainly find it in the website of the IC25 (www.ecgsummit.com), once it is available, together with the previous International Criteria published in 201719. This web will also host a training course on ECG interpretation in athletes specially aimed to assist sports medicine physicians and sports cardiologist around the world to get confidence on the interpretation of ECG in athletes using the most recent criteria.
C. Role of Echocardiography in the Cardiac Screening of Football Players
The systematic use of echocardiograms in the cardiac screening of football players has been relevant to identify structural conditions not associated with ECG abnormalities in asymptomatic players, such as anomalous coronary arteries (CAA), that constitute 11-13% of cases of SCDs in USA and Italy respectively26,27, aortopathy and other congenital abnormalities.
In 2025 FIFA has issued specific recommendations for the cardiac screening in youth football28 that follows available ESC guidelines15 and therefore transthoracic echocardiography is not recommended for routine cardiac screening of youth football players, although “it may be considered as an adjunct to medical history, physical examination and 12-lead ECG to enhance detection of high-risk congenital anatomic coronary artery anomalies and aortic disease, assuming high-quality imaging, proper expertise and sufficient resources for interpretation and management of findings are available”28. This seems to be a sensitive approach considering the high number of young participants in football around the world and the limited access to echocardiography. Although if we observed data on Table 1 reflecting the outcome of the cardiac screening for different population of football players, adolescent athletes are among those with highest prevalence of conditions associated with SCD (0.38%)29 and with higher overall incidence of abnormal findings (4.5%)30. Thanks to the routine echocardiography in the cardiac screening of pre-adolescent football players, Calo et al30 identified cardiac abnormalities in 91 asymptomatic athletes with a completely normal ECG and almost normal physical examinations. Similarly, Malhotra et al29 found two cases of anomalous coronary arteries, one bicuspid aortic valve requiring surgery and one arrhythmogenic cardiomyopathy, a condition responsible for 13% of athlete sudden cardiac deaths in the UK31, all of them with normal history, physical examination and ECG.
Although marginal to the value of the ECG adding the echocardiography on the first screening, we improve the identification of players with cardiac pathology at risk of SCD. A recent survey of cardiologist by the ESC32 has shown that most cardiologist also include echocardiography on the routine assessment of asymptomatic athletes; this is also common practice at Aspetar, not only in football players but to all athletes presenting for their first assessment. The question is, once the player has undergone echocardiography on their first assessment and these pathologies have been ruled out, whether serial echocardiography has any role in the cardiac evaluation of the players in addition to the history, physical examination and the ECG that will remain the cornerstone of the periodic cardiac screening. What would be the goal of this ‘periodic echocardiography’? We may argue that it would be to detect abnormal cardiac remodelling, uncover early phenotypic manifestations of cardiomyopathies, pericardial pathology or myocardial abnormalities associated with cardiac dysfunction, i.e. myocarditis etc. But is very likely that all those situations are associated with symptoms or abnormal findings in the ECG and therefore the systematic inclusion of the echocardiography may not be necessary after the first assessment, being the test indicated as second line investigation for those with abnormal findings. This question remains to my understanding a crucial point if we aim to optimize scarce resources. Reducing unnecessary routine echocardiography, we may use these resources to do more ‘first time echocardiography’ when it may be more beneficial. It is reasonable to propose that, if an echocardiogram is to be conducted in a football player, the most appropriate timing would be during adolescence in order to rule out serious pathology instead of having the diagnosis done once they became professionals – if they do not suffer a major adverse cardiac event while playing football in a junior team with otherwise more limited access to emergency action plans and AED than in adult teams- when career and economic implications of such a diagnosis are much relevant.
In the other hand, FIFA caution against the use of echocardiography in the absence of experienced sports cardiologists not familiar with current echocardiographic guidelines and/or in the assessment of athletes33: “The echocardiography should be performed by a designated physician and expert in echocardiography with particular experience in the assessment of athletes. The examination should be based on the internationally accepted echo guidelines in “non-athletes”. However, as athletes may exhibit physiologic deviations from conventional “ranges of normal”, we also refer to corresponding specific sports cardiology literature”.
D. Role of the Exercise Test in the Cardiac Screening of Football Players
Football players over 35 years of age may be at greater risk of SCD due to coronary artery disease (CAD)34,35, reason why FIFA include the exercise test as complementary investigations for players on this category, independently of their individual cardiovascular risk, including referees and assistant referees too in the same category irrespectively of their age or cardiovascular risk profile. In addition, considering the low diagnostic yield of the traditional stress test for detecting subclinical CAD, the routine inclusion of this test in the cardiac screening of football players/referees seems very questionable.
The performance of the traditional stress ECG to detect CAD in asymptomatic players is very low, according with a recent metanalysis36 the pooled sensitivity of the test is 66% with specificity of 61% to detect CAD. These values can be improved significantly using cardiopulmonary exercise test (CPET) with 88% sensitivity and 98% specificity to detect CAD37 but this is not the test most players/referees undergo, reducing the diagnostic yield of the investigation.
Therefore, indicating the test as second line investigation based on individual risk assessment and choosing to do CPET instead of traditional stress test would certainly improve the performance of the test on the screening of football players and referees. Again, it requires resources and expertise for the performance and interpretation of the results.
PARTICULARITIES OF CARDIAC SCREENING IN DIFFERENT SUBPOPULATIONS OF FOOTBALL PLAYERS
A. Outcomes of Cardiac Screening in the adolescent football player
While cumulative training loads may be relatively low in the preadolescent/adolescent age group, 65% of athlete SCD occurs before the age of 1738 and one of the highest incidences of SCD in athletes (6.8/100,000 person years) had been reported among adolescent football players29.
Cardiac screening in adolescents is very challenging as physiological growth and athletic remodelling overlap with possible changes that may be due to the early manifestations of structural pathologies, such as the most common forms of cardiomyopathies associated with SCD (i.e. HCM). These cardiomyopathies exhibit and age-related penetrance, being the puberty a well-known period for the early development of the phenotypic manifestations of the disease that may further blurred the ECG and echocardiography findings in this age group.
Recent recommendations for cardiovascular screening in youth football players launched by FIFA28 follow the recommendations of the ESC15 considering the history – personal and family – together with the physical examination and the resting ECG the bases of the cardiac screening that youth players should undergo periodically starting at the age of 12-14 years, every 2-3 years, instead of the annual assessment that is required in adults players.
According to research from Malholtra et al22 the International criteria for ECG interpretations can be applied to adolescent football players with a 98% specificity and 86% sensitivity for detecting serious cardiac pathology. Biological maturation is a key consideration in athletes ECG interpretation as has been shown in the study of McClean et al39 demonstrating that biological age rather than chronological age should guide the interpretation of ECG on this population.
Outcome of cardiac screening in adolescent soccer players (Table 1) shows that younger pre-adolescents’ players have a higher prevalence of cardiac abnormalities (4.5% abnormal findings) but with low incidence of pathology associated with SCD (0.09%)30, while more mature adolescents show a lower prevalence of cardiac abnormalities (2.38%) but much higher incidence of pathology associated with SCD (0.38%)29.
B. Outcomes of Cardiac Screening in the female football player
White females athletes may have a 6 fold lower incidence of SCD than male athletes25, although a recent study conducted in UK10 have shown similar prevalence of disease associated with SCD between male and female football players. On this study females’ footballers had a lower prevalence of sinus bradycardia, sinus arrhythmia, left and right ventricular hypertrophy but a longer PR and QTc intervals, which is in accordance with observation from other sports. Similarly anterior T-wave inversion (TWI) was more common in female players (12.2%) – finding observed in up to 19% of female endurance athletes40 – which may be due to the anatomical differences in chest wall structure, specifically breast tissue41.
On the study of Yamagata et al10 female football players showed a higher prevalence of symptoms when compared with their male counterparts (9.1% vs 4.9%) although only 5.3% of this population required additional investigations vs 7.4% of the male. Although not statistically significant, the percentage of female footballers identify with cardiac disorders associated with SCD, was lower than male 0.2% vs 0.37%; overall female players had lower prevalence of cardiac pathology than male players: 1.1% vs 2%. Over a follow-up of 6.1 ± 4.7 years there were no cases of SCD among the female football player screened, but there was one case (0.03%) of non-ischemic cardiomyopathy diagnosed 18 months post-screening.
C. Outcomes of Cardiac Screening in the paralympic football player
Para-football players represent a broad range of eligible impairments, including paraplegia, visual or hearing impairment, and cerebral palsy. These individuals may harbor potentially serious cardiac disease, which in some cases may remain undetected, placing them at higher risk of adverse cardiovascular events while playing football.
In a recent study by Yamagata et al42, 156 paralympic football players competing internationally underwent PCMA and results were compared with no para football players. The cohort comprised 41 (26.3%) blind players, 15 (9.6%) partially sighted players, 72 (46.2%) deaf players and 28 (17.9%) players with cerebral palsy. Approximately a quarter of the players in the present study reported symptoms suggestive of potential cardiac issues (21.8% of para players vs 4.6% non para players), with this proportion rising to one-third among female para-football players (33.3% female para players vs 17.1% male para players). The referral rate for further evaluation was twice as frequent among para players than non-para-players (14.7% vs 6.6%). In this study, para-football players were three times more likely to be diagnosed with a cardiac condition requiring management and/or surveillance compared with non-para players and had a higher prevalence of serious cardiac disease associated with SCD: 2.6% para-football players vs 0.3% non-para players (p=0.005). In total, 6.4% para-football players were diagnosed with cardiac pathology versus 2.1% non-para-football players.
Cardiac screening is warranted in this growing cohort of players to identify at-risk individuals, existing some challenges on the assessment of this population as available evidences and current cardiology recommendations for sports participation, are primarily based on data from non-para players which may not align with the unique cardiovascular profile of this population who have demonstrated a higher frequency of follow-ups and investigations, as well as a greater prevalence of cardiac conditions associated with SCD42.
FROM THE PRESENT TO THE FUTURE OF CARDIAC SCREENING IN FOOTBALL
It may be time to evaluate which should be the best long-term strategy on the cardiovascular assessment of football players around the world, both professionals and recreational, considering the still existing limitation to access healthcare resources in certain parts of the world and inequality access for cardiac screening to recreational players. Transfer of football players in first division and second division around the world is a multimillion-dollar business, clubs will still want to ensure new players are able to play at the top of their capacity with no additional “unknown” cardiac risks to be mitigated and they very likely will continue requiring a comprehensive cardiac assessment before recruitment and periodically. However, football is a sport played worldwide by more than 265 million registered players and a huge majority of recreational and non-elite competitive football players are without access to basic cardiac screening (including history, physical examination and ECG) as recommended by scientific medical societies, being more at risk of SCD than elite/professional players.
Some questions remain unanswered regarding the tools required for first vs repeated cardiac screening as well as the periodicity to maximize cost effectiveness. Certain groups of players seem to have a higher incidence of SCD related disease; therefore, a tailored screening should consider individual risk of the player including: traditional risk factors (hypertension, smoking etc.), age, ethnicity, sex and paralympic condition, avoiding the systematic indication of tests with low diagnostic yield to detect conditions associated with SCD, such as the traditional exercise test.
Recent advances in artificial intelligence (AI), wearables, and remote monitoring offer promising adjuncts to traditional screening. AI-enhanced ECG analysis may detect subtle conduction or repolarization abnormalities preceding overt disease, similarly, ECG interpretation with deep learning can reduce false positives on ECG interpretation. While these technologies cannot yet provide definitive diagnosis independently, they may enhance risk stratification (i.e. AI can integrate multimodal data of ECG, imaging, biomarkers, family history etc. to generate individualized risk scores) and improve longitudinal monitoring for those with abnormal findings or symptoms. How telehealth and AI algorithm will help sports physicians and sports cardiologists around the world to better differentiate normality/abnormality in the ECGs and imaging of the heart of players providing more easy access to affordable resources for the underprivileged ones is still to see but I believe these new resources will facilitate the expansion of cardiac screening beyond current reach.
FIFA is currently undergoing a review of his PCMA. How future recommendations will shape the cardiac screening in football players around the world is still a pending matter at the time of writing this article, but it certainly should address some of the questions we have highlighted. We hope that PCMA will increase its current reach beyond professional and elite players to the wide range of recreational and amateur football players, both male and female and para-players enthusiast around the world with basic, affordable and accessible cardiac screening recommendations, similarly to the youth football player. That would be the biggest challenge to come.
Maria‑Carmen Adamuz PhD, MD
Cardiologist
Aspetar Orthopaedic and Sports Medicine Hospital
Doha, Qatar
Contact:
mariadelcarmen.adamuz@aspetar.com
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