Commentary on Sports and Exercise Cardiology in the United States

Participation in sports in the United States is at an all-time high. The number of high school athletes is approaching 8 million.1 The number of finishers in U.S. running events in 2012 surpassed 15.5 million.2 The percentage of the population who participates in informal sporting activities is considerably larger but difficult to measure. Approximately 50% of adults met the federal aerobic physical activity guidelines in 2012.3

The vast majority of medical conditions that prompt athletes to seek medical care are musculoskeletal in origin. Most of these conditions are symptomatic, self-limiting, and non-life threatening. The medical delivery system is structured to address these issues. Simple conditions are usually treated by primary care givers. More complex conditions are referred to sports medicine clinics which are abundant in most cities. These clinics are staffed by physiatrists, orthopedists, and physical therapists who have advanced training in sports medicine. Treatment regimens are fairly uniform and well-established.

A smaller number of athletes encounter the medical system because of a cardiovascular issue. In contrast to sports medicine conditions, many of the cardiovascular diagnoses are sporadic, such as syncope, or completely asymptomatic, such as an abnormality on the electrocardiogram. These conditions frequently are chronic or permanent and may be potentially life-threatening with major implications affecting athletic participation. Distinguishing a truly pathologic entity from the effects of athletic training (e.g., myocardial hypertrophy) can be challenging. The electrocardiogram, usually the first test to be ordered when cardiac issues are suspected, may appear to be abnormal by usual adult standards in healthy adolescents and athletes at any age. The physician evaluating the athlete may have little awareness of the impact of treatment on athletic performance. The number of clinics providing specialized cardiovascular care for athletes is limited. Most decisions regarding athletic participation are opinion-based, as there is little evidence-based literature to inform these decisions, even when opinions are published as "guidelines."4

In the April 22, 2014 issue of the Journal of the American College of Cardiology, Lawless and colleagues published a state-of-the-art paper, "Sports and Exercise Cardiology in the United States: Cardiovascular Specialists as Members of the Athlete Healthcare Team."5 This seminal work accurately and comprehensively summarizes the current state of sports cardiology in the United States. The authors illustrate how athletes represent unique cardiac patients who may warrant different diagnostic and therapeutic considerations compared to non-athletes. They identify many limitations in the current system, including the lack of knowledge for informed clinical decision making, the absence of formal training programs for cardiovascular care in the athlete, and the paucity of high-quality research studies that authoritatively address relevant clinical issues. The authors propose a new paradigm to improve the cardiovascular care of athletes. Key features of this approach include an athlete-centered clinical care model, the development of an athlete-specific knowledge base, the creation of athlete-specific diagnostic tests, incorporation of exposure to athletes with cardiovascular issues into educational training programs, development of registries, performance of high-quality research, and dissemination of an athlete healthcare delivery system.

This document essentially functions as a vision statement for the newly formed Sports and Exercise Council within the American College of Cardiology. It focuses attention on the importance of cardiovascular care in athletes. By clearly articulating the limitations that exist in the current healthcare system, Lawless et al. identify deficiencies that need to be addressed.5 Their proposed new paradigm for the cardiovascular care of athletes provides a blueprint describing how to proceed moving forward. Achieving the goals outlined in this document will be challenging. Specific challenges for academic medical centers include incorporating exposure to athletes with cardiovascular issues into training programs and supporting research projects that investigate cardiovascular issues in athletes. The establishment of registries will expand the knowledge base and help to identify the topics most worthy of additional research efforts. During the past two decades the American College of Cardiology has enhanced the care of patients with cardiovascular diseases in general through the development of guidelines that are evidence-based. The future care of athletes with cardiovascular issues should be based upon this same model.


  1. High school sports participation increases for 24th consecutive year. National Federation of State High School Associations Website. Available at: Accessed 7/17/2014.
  2. 2013 State of the sport – part III: U.S. race trends. Running USA Website. 28 Jul 2013. Available at: Accessed 7/17/2014.
  3. Health, United States, 2013: with special feature on prescription drugs. U.S. Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics. May 2014. DHHS Publication No. 2014-1232.
  4. Maron BJ, Zipes DP. 36th Bethesda Conference: Eligibility recommendations for competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol 2005;45:1313-15.
  5. Lawless CE, Olshansky B, Washington RL, et al. Sports and exercise cardiology in the United States: cardiovascular specialists as members of the athlete healthcare team. J Am Coll Cardiol 2014;63:1461-72.

Keywords: Athletes, Diagnostic Tests, Routine, Exercise, Sports

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