The 2025 American College of Cardiology (ACC) Scientific Session & Expo (ACC.25), held in Chicago, Illinois, featured groundbreaking updates in sports cardiology. Below is a summary of the session highlights.

Milestone Year in Sports Cardiology

This year was pivotal with two major guideline releases:

1. 2025 American Heart Association(AHA)/ACC scientific statement on sports participation for athletes with cardiovascular abnormalities—an update of the 2015 guidelines, it emphasizes new evidence and a transition to shared decision-making (SDM).¹
2. 2024 Heart Rhythm Society (HRS) expert consensus statement on arrhythmias in athletes—the HRS's first dedicated guidance on this topic.²

These documents reflect evolving data and ethics, positioning SDM as a moral imperative in managing athletes with heart disease.³ Notably, recent data suggest athletes with cardiomyopathies (except PKP2 arrhythmogenic cardiomyopathy) may not be at higher arrhythmic risk than nonathletes, allowing for more personalized return-to-play (RTP) decisions.⁴ A new sports classification paradigm introduced this year considers individualized strength–endurance demands by sport and athlete role, supporting a move away from rigid restrictions toward an SDM model. Athlete-specific adaptations influence arrhythmia risk and require tailored approaches—justifying the need for the new HRS guidelines.

Presenters: Drs. Jonathan Kim, Aaron Baggish, Benjamin Levine, Sharlene Day, Rachel Lampert

Late-Breaking Clinical Trials

In their observational study, Survival Outcomes after Sudden Cardiac Arrest in Young Competitive Athletes From the United States, Petek et al. found that, in 641 athletes with sudden cardiac arrest (SCA) over a 9-year period, there was a 49% survival rate, with Black or other nonwhite race, nonexertional SCA, and SCA during practice/training all associated with lower survival rates.⁵ These results emphasize the need to address disparities and improve emergency action plans (EAPs). In their cohort study, Cardiac Arrest During Long-Distance Running Races (RACER-2), Kim et al. found that, since 2010, compared with 2000-2009 (RACER-1), while SCA incidence during marathons has remained stable, mortality has decreased by approximately 50%, likely due to better EAPs.⁶

Presenters: Drs. Jonathan Kim, Bradley Petek

Preparticipation Screening

Key elements include thorough personal and family history, screening for stimulant use, and contextual interpretation of athlete electrocardiograms (ECGs) using the international criteria. However, considering autopsy-negative cases of sudden cardiac death (SCD), it is important to have a nuanced, context-driven approach to ECG analysis to ensure athlete safety. Racial disparities exist in SCD and screening outcomes. However, race is not a proxy for risk—social determinants of health are more relevant and should be prioritized.⁷

Presenters: Drs. J. Sawalla Guseh, Mustafa Husaini, Jonathan Kim

Coronary Artery Disease in Athletes

Athletes often have high coronary artery calcium (CAC) scores due to prolonged exercise, yet their plaques are typically stable. Computed tomography angiography and CAC scoring assist in risk stratification. Statins may help mitigate risk; athletes should also warm up properly, avoid sprint finishes, and manage low-density lipoprotein cholesterol levels. Traditional exercise stress testing thresholds (85% max hazard ratio [HR]) are outdated for athletes. They should be tested to maximal exertion unless high-risk features arise. Revascularization may be favored in symptomatic or high-risk coronary artery disease (CAD) cases, but medical therapy with risk control remains valid for stable CAD. Functional tests such as fractional flow reserve and instantaneous wave-free ratio (iFR [Philips]) may underestimate ischemia in athletes.

Presenters: Drs. Ankit Shah, Meagan Wasfy, Tamanna Singh, Aaron Baggish

Atrial Fibrillation Management: Ablation vs. Medical Management

Ablation is effective for long-term relief, especially in athletes with paroxysmal atrial fibrillation treated early. Medications such as beta-blockers or calcium channel blockers are poorly tolerated in this group. However, class Ic agents may be cautiously used.⁸ Medical management, emphasizing risk-factor modification, avoids procedural risks and remains effective. Even in patients who undergo ablation, those with aggressive lifestyle changes fare better long term.⁹

Presenters: Drs. Eugene Chung, Elizabeth Dineen, Aaron Baggish

Risk Stratification, RTP, and EAPs

A study of Division 1/professional athletes with SCD-associated diagnoses found that 75% were initially disqualified, but 96% returned to play safely after SDM and further evaluation.⁴ Cardiac magnetic resonance imaging evaluation for myocardial scar burden may play a role in risk stratification. Site-specific EAPs and automated external defibrillators, along with regular drills, remain critical life-saving tools.

Presenters: Drs. Matthew Martinez, Eli Friedman, Leandro Zimerman

Athletes With Implantable Cardioverter-Defibrillators

Management must be tailored. For sports involving upper-body movement, subcutaneous implantable cardioverter-defibrillators are preferred to reduce lead complications; stress testing is essential to check for inappropriate sensing.

Presenter: Dr. Mark Link

Cardiac Medication Use in Competitive Athletes

Medication use should consider the impact on performance, safety, and doping regulations. Athletes may need to apply for therapeutic-use exemptions when indicated.

Presenter: Dr. Dermot Phelan

Aortic Remodeling

Athletes with tricuspid aortic valves may show mild enlargement, but size alone does not predict dissection risk. In patients with bicuspid valves, aortic size may be larger, but there is no evidence sports increase aortic size.¹⁰ Genetic conditions such as Marfan or Loeys-Dietz syndromes require special consideration.

Presenter: Dr. Dermot Phelan

Exercise-Induced Arrhythmogenic Cardiomyopathy

Chronic endurance training may disproportionately stress the right ventricle, leading to dysfunction or arrhythmias even in the absence of known mutations.¹¹ Advanced imaging is key for diagnosis and risk stratification.

Presenter: Dr. André La Gerche

Pediatric Considerations

For the pediatric athlete at increased arrhythmia risk, the data also support that blanket sports restrictions are harmful, contributing to obesity and mental health conditions, and thus should only be used when clearly indicated. Instead, an approach grounded in SDM that supports safe RTP for patients with cardiomyopathies with disease-specific therapies and ongoing monitoring should be pursued.

Presenter: Dr. Susan Etheridge

Conclusion

This year's updates emphasize a paradigm shift in sports cardiology—moving toward personalized care grounded in SDM, advanced imaging, and emergency preparedness.

References

1. Kim JH, Baggish AL, Levine BD, et al. Clinical considerations for competitive sports participation for athletes with cardiovascular abnormalities: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2025;85(10):1059-1108. doi:10.1016/j.jacc.2024.12.025.
2. Lampert R, Chung EH, Ackerman MJ, et al. 2024 HRS expert consensus statement on arrhythmias in the athlete: evaluation, treatment, and return to play. Heart Rhythm. 2024;21(10):e151-e252. doi:10.1016/j.hrthm.2024.05.018.
3. Baggish AL, Ackerman MJ, Lampert R. Competitive sport participation among athletes with heart disease: a call for a paradigm shift in decision making. Circulation. 2017;136(17):1569-1571. doi:10.1161/CIRCULATIONAHA.117.029639.
4. Martinez KA, Bos JM, Baggish AL, et al. Return-to-play for elite athletes with genetic heart diseases predisposing to sudden cardiac death. J Am Coll Cardiol. 2023;82(8):661-670. doi:10.1016/j.jacc.2023.05.059.
5. Petek BJ, Churchill TW, Moulson N, et al. Survival outcomes after sudden cardiac arrest in young competitive athletes from the United States. J Am Coll Cardiol. 2025;85(17):1682-1692. doi:10.1016/j.jacc.2025.03.006.
6. Kim JH, Rim AJ, Miller JT, et al. Cardiac arrest during long-distance running races. JAMA. Published online March 30, 2025. doi:10.1001/jama.2025.3026.
7. Krishnan S, Guseh JS, Chukumerije M, et al. Racial disparities in sports cardiology: a review. JAMA Cardiol. 2024;9(10):935-943. doi:10.1001/jamacardio.2024.1899.
8. Mandsager KT, Phelan DM, Diab M, et al. Outcomes of pulmonary vein isolation in athletes. JACC Clin Electrophysiol. 2020;6(10):1265-1274. doi:10.1016/j.jacep.2020.05.009.
9. Pathak RK, Middeldorp ME, Lau DH, et al. Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: the ARREST-AF cohort study. J Am Coll Cardiol. 2014;64(21):2222-2231. doi:10.1016/j.jacc.2014.09.028.
10. Schreurs BA, Hopman MTE, Bakker CM, et al. Associations of lifelong exercise characteristics with valvular function and aortic diameters in patients with a bicuspid aortic valve. J Am Heart Assoc. 2024;13(3):e031850. doi:10.1161/JAHA.123.031850.
11. La Gerche A. Exercise-induced arrhythmogenic (right ventricular) cardiomyopathy is real…if you consider it. JACC Cardiovasc Imaging. 2021;14(1):159-161. doi:10.1016/j.jcmg.2020.09.014.