The 2026 Care of the Athletic Heart was a 1-day preconference held in advance of the American College of Cardiology Annual Scientific Session. The session, hosted by Dr. Jeffrey Hsu, welcomed guests from over 14 countries and aimed to deliver focused, practical updates in sports cardiology, while providing education and insight into this rapidly evolving field.

The session was highly interactive, featuring electrocardiogram (ECG) challenges and topic debates that were thought-provoking, engaging, and infused with humor. The atmosphere was welcoming and inclusive, with attendees seated in table-based groups that included at least one faculty member to facilitate networking and discussion.

Early in the session, key publications from the preceding year were reviewed. An important observation highlighted the rapid growth in sports cardiology research, with publications increasing from 120 in 2011 to 1,132 in 2025, reflecting substantial academic expansion and overall interest in the field. Among the notable studies, new data from the RACER2 (Race Associated Cardiac Event Registry) study evaluated the contemporary incidence of sudden cardiac arrest (SCA) in long-distance running. Despite increased participation in US long-distance running events, the incidence of cardiac arrest has remained stable, while case fatality declined by approximately 50%. This reduction in mortality may be attributed to more effective emergency action planning with immediate access to defibrillation. Coronary artery disease was the most common etiology among cases with identified causes.¹

Additionally, a cardiac screening study (including questionnaire, ECG, and selective echocardiography) in individuals aged 14-35 years identified conditions associated with SCA or sudden cardiac death (SCD) in 0.3% of participants. At 6-year follow-up, 0.08% of individuals initially cleared were later diagnosed with such conditions or experienced SCA/SCD, which potentially represents delayed penetrance, supporting the need for serial evaluation.²

A follow-up study of 274 genotype-positive, phenotype-negative (G+/P-) athletes cleared for return to play demonstrated no cardiac events or deaths related to genetic heart disease over 1,300 combined patient-years, suggesting that sports participation for most (G+/P-) athletes is safe.³

The role of cardiopulmonary exercise testing was discussed by Dr. Ben Levine. Key principles included exercising patients to maximal effort using protocols emphasizing continuous ramp rather than the Bruce protocol. Participants were also challenged with engaging case-based scenarios and guidance for implementing exercise prescription using ventilatory thresholds.

An overview of cardiovascular imaging provided several practical insights. With increasing numbers of masters athletes (aged ≥35 years), clinicians were reminded to consider age when interpreting imaging findings, to help distinguish physiological adaptation from pathology. Multimodality imaging offers significant value in this population but requires careful and informed interpretation. On cardiac magnetic resonance imaging, late gadolinium enhancement may be present in up to 10-47% of asymptomatic masters athletes, with distribution patterns (e.g., right ventricular [RV] insertion site vs. subendocardial) helping to clarify etiology.⁴ Common pitfalls in imaging athletes include overestimation of interventricular septal thickness due to inclusion of RV trabeculations, and overestimation of right atrial pressure based on inferior vena cava measurements, which may lead to misdiagnosis of pulmonary hypertension.

The conference also provided mentorship on establishing a sports cardiology practice. Speakers emphasized the broad community need and the potential impact at all levels of sport. Attendees were encouraged to engage locally, including with high schools and public service sectors such as fire and police departments. It was widely agreed that high-quality practice at the community level often serves as a foundation for progression to elite and professional sports settings.

The management of the tactical athlete (TA) was emphasized throughout the conference. TAs include individuals in occupations requiring high physical fitness and exposure to extreme stress, such as firefighters, police officers, emergency medical personnel, military members, and astronauts.⁵ SCD accounts for over one-half of line-of-duty fatalities among firefighters.⁶ These risks extend beyond the individual, affecting team safety during emergency operations.

The session concluded with case-based debates, including a compelling mentor–mentee exchange and a high-level "clash of the titans." These discussions were both educational and entertaining, ending the conference on a high note. Overall, the preconference was an exceptional experience and is highly recommended for anyone interested in sports cardiology.

References

1. Kim JH, Rim AJ, Miller JT, et al. Cardiac arrest during long-distance running races. JAMA. 2025;333(19):1699-1707. doi:10.1001/jama.2025.3026
2. MacLachlan H, Bhatia R, Raju H, et al. Cardiac screening for conditions associated with sudden cardiac death: yield, interventions, and SCA/SCD incidence in 104,369 young individuals. J Am Coll Cardiol. 2026;87(7):756-768. doi:10.1016/j.jacc.2025.11.049
3. Martinez KA, Bos JM, Tobert KE, Giudicessi JR, Ackerman MJ. Outcomes and burdens to return-to-play for phenotype negative athletes with a genetic heart disease. JACC Clin Electrophysiol. 2025;11(8):1708-1717. doi:10.1016/j.jacep.2025.03.013
4. Phelan DM, Claessen G, Eijsvogels TMH, et al. Cardiovascular imaging considerations for masters-aged athletes. JACC Cardiovasc Imaging. 2026;19(4):538-550. doi:10.1016/j.jcmg.2025.10.024
5. Xu J, Haigney MC, Levine BD, Dineen EH. The tactical athlete: definitions, cardiovascular assessment, and management, and "fit for duty" standards. Cardiol Clin. 2023;41(1):93-105. doi:10.1016/j.ccl.2022.08.008
6. U.S. Fire Administration [Internet]. Annual Report on Firefighter Fatalities in the United States. 2024. Available at: https://www.usfa.fema.gov/statistics/reports/ firefighters-departments/firefighter-fatalities.html. Accessed 06/25/2026.