The JACC state-of-the-art review on the Cardiovascular Care of the Pediatric Athlete is a comprehensive and timely guide for providers managing cardiovascular (CV) health in pediatric athletes, defined as individuals 5-17 years of age who participate in organized and recreational sports.¹ The authors discuss etiologies and evaluation of sudden cardiac arrest (SCA), exercise-induced cardiac remodeling (EICR), essential aspects of preparticipation screening, and clinical evaluation of symptomatic athletes. Perspectives on select cardiac conditions that may increase risk are also addressed. The JACC state-of-the-art review follows the 2025 American Heart Association/American College of Cardiology (AHA/ACC) scientific statement on Clinical Considerations for Competitive Sports Participation for Athletes with CV Abnormalities.^1,2 Similarities among the documents include the necessity of shared decision-making (SDM), the acknowledgment that EICR can be difficult to distinguish from pathology, and recognition of the vital importance of widespread availability of cardiopulmonary resuscitation and automated external defibrillators. The guideline updates herein build on momentum created by multiple publications in the past year updating CV care for patients with hypertrophic cardiomyopathy,³ athletes with arrhythmia,⁴ and CV management of aortopathy in children.⁵ As the field of sports cardiology rapidly evolves, the inclusion of pediatric sports cardiology is essential given the large percentage of youth participating in organized sports and the importance of physical activity in youth for optimal mental and physical well-being.

How is CV Care of Pediatric Athletes Different From That of Adults?

Unique challenges distinguish pediatric from adult athletes and are well summarized in the JACC state-of-the-art review.¹ Pediatric athletes may not be able to discern pathologic symptoms from normal physiological exercise response and may have difficulty describing the sensation (e.g., palpitations described as chest pain). This may present confusion for athletes with exertional symptoms or with known cardiac disease who cannot succinctly communicate their symptoms. Athletes 5-7 years of age typically self-limit if they are feeling unwell, whereas the competitive adolescent or teenager is more likely to push through to complete exhaustion.

There is often a scarcity of pediatric data for a population marked by somatic growth and rapid physiological change. From medications to guidelines, pediatric providers historically extrapolate from data-driven adult medicine. Similarly, pediatric cardiologists have historically restricted children on the basis of extrapolation of adult risks. An adolescent with a well-functioning bicuspid aortic valve, for example, may be over-restricted from sports on the basis of the risk of aortic dissection in adults.

Finally, the authors note that longitudinal follow-up and serial reassessment are necessary for a population hallmarked by rapid growth and pubertal changes, as well as the age-related penetrance of cardiomyopathies.¹ Patients and families must understand this concept as opposed to a single sports clearance; however, the authors note that there are no data supporting how frequently re-evaluations should occur.

Leveling the Athletic Playing Field

There is, for the first time, a document to specifically guide providers who care for young athletes. The JACC state-of-the-art review approaches this topic in a time of highly publicized events of SCA in athletes and a history of default disqualification for patients with congenital and acquired heart disease.¹ This document, along with landmark updates in the past year, moves away from a paternalistic and restrictive approach, considering sports classification as a continuum and emphasizing SDM.^1,3

Physical activity is integral to healthy childhood development, and this remains true for children with heart disease. Furthermore, battling the obesity epidemic requires a multifaceted approach that starts prior to adulthood. The encouragement of exercise and inclusion of all youth into physical activity, at whatever level and sport most appropriate, works toward establishing healthy habits rather than a lifetime of sedentary behavior.

The 2025 AHA/ACC scientific statement on athletes with CV abnormalities discusses the vital necessity to update care of all patients with congenital and acquired heart disease.² However, most athletes do not have access to high-level sports cardiology expertise. For athletes between 5 and 17 years of age, especially those with heart disease, the demand for sports cardiology expertise continues to outpace supply. This current review complements existing guidance to increase access for patients and practitioners of all levels.

Challenges and the Future of Pediatric Sports Cardiology

It is difficult to convince a patient, previously told not to exercise on the basis of guidance from a decade ago, that exercise is now thought to be safe and may improve longevity and quality of life. The pediatric cardiologist is tasked with providing the patients' decision-makers (most commonly their parents) the time necessary for SDM as prior recommendations are updated. Although the risk of exercise in some patients is not zero, the cost of unnecessarily restricting pediatric athletes is certainly high. As pediatric cardiologists adopt the linear model of sports classifications rather than the singular static versus dynamic activities, confusion and unanticipated delays in clearance may result.¹ The preparticipation physical (i.e., sports clearance form) must be easily interpretable despite the hours of SDM necessary. Not unlike the adult cardiologist who advocates for a heart-healthy lifestyle with exercise recommendations, the pediatric cardiologist must emphasize the importance of movement and play in even the youngest patients. Pediatric cardiologists can strengthen their patient populations by offering expertise of dedicated sports cardiology teams who address the nuances of EICR, provide age- and sport-specific exercise testing, and facilitate return-to-play for athletes. Pediatric sports cardiology requires individuals with passion for the field, interest in physiological adaptation of exercise, and attentiveness to nuances of sports for athletes with and without heart disease.

Conclusion

Despite differences between pediatric and adult cardiology, equity in care remains of utmost importance. The JACC state-of-the-art review offers guidance for all levels of providers while highlighting the need for multidisciplinary collaboration and widespread advocacy to improve outcomes of SCA.¹ As pediatric cardiologists empower their young patients to exercise while developing and using emergency action plans, they will help grow healthier adults and, along the way, make communities safer for people of all ages.

References

1. Dean PN, Brothers JA, Burns K, et al. The cardiovascular care of the pediatric athlete. J Am Coll Cardiol. 2025;85(13):1434-1454. doi:10.1016/j.jacc.2025.02.010
2. 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
3. Writing Committee Members, Ommen SR, Ho CY, et al. 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR guideline for the management of hypertrophic cardiomyopathy: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines [published correction appears in J Am Coll Cardiol. 2024 Oct 29;84(18):1771. doi: 10.1016/j.jacc.2024.08.055.]. J Am Coll Cardiol. 2024;83(23):2324-2405. doi:10.1016/j.jacc.2024.02.014
4. 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
5. Morris SA, Flyer JN, Yetman AT, et al. Cardiovascular management of aortopathy in children: a scientific statement from the American Heart Association. Circulation. 2024;150(11):e228-e254. doi:10.1161/CIR.0000000000001265