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October 13, 2025
6 min read
Key takeaways:
- All cardiologists who care for young patients should have understanding of sports cardiology.
- Pediatric sports cardiologists can be valuable resource to general pediatric cardiologists and adult sports cardiologists.
Sports cardiology is often thought of as an adult cardiology domain, but an understanding of sports cardiology is critical for all pediatric cardiology practitioners.
Data suggest that 60% to 70% of middle and high school students play organized sports, and there are more who participate in non-organized sports. Additionally, parents frequently ask about future sports participation and physical activity restrictions for their child, even during fetal cardiology consultations or in the newborn period. It is important to recognize the significant long-term implications of restricting physical activity, both related to social-emotional development and the impact of activity restriction on healthy lifestyle habits that extend into adulthood.
Understanding the effect of exercise on children
All pediatric cardiology practitioners should have a comprehensive understanding of expected physiologic changes during exercise in children as well as symptoms and exam findings that warrant further investigation.
Mason Stevens
Many of the same exercise-induced physiologic adaptations occur in both children and adults, but there are several important differences. Systolic blood pressure, for example, increases during exercise in children, but normative resting and peak exercise pressures are lower than adults and gradually increase throughout adolescent and teenage years. Children also have higher heart rates, both at rest and during exercise, because their smaller cardiac chambers generate lower stroke volumes. Furthermore, heart rate recovery is faster in children than in adults and can make evaluations such as stress echocardiography more challenging.
Mara Weigner
Exercise capacity progressively increases as children age, which can be measured as peak oxygen consumption (peak VO2) on cardiopulmonary exercise tests. Exercise-induced cardiac remodeling occurs in the pediatric population as in adults and includes relative left ventricular hypertrophy, left and right cardiac chamber dilation and increased LV concentricity. Similar to adults, electrical adaptations of sinus bradycardia, prolonged PR interval and increased QRS voltages may develop with increased athletic conditioning.
Peter Dean
Unsurprisingly, there is often a “gray zone” in athletes of all ages where it may be difficult to distinguish normal exercise-induced adaptation from underlying pathology. In the pediatric population, this is confounded by a lack of normative standards. Unfortunately, there is not one specific “athlete heart” phenotype with standardized adaptations to match specific types and intensities of athletic training.
Symptoms to investigate
Some of the symptoms commonly addressed in pediatric cardiology clinics include chest pain, syncope and palpitations, which can be challenging to evaluate. Unlike adults, chest pain in youths is most often benign. However, when it occurs in the setting of exertion, with syncope or near syncope, or in conjunction with a family history of confirmed or suspected sudden cardiac arrest or death, further investigation is warranted. Evaluations may require a high index of suspicion if young children are unable to recall or articulate their symptoms.
Syncope during exercise and/or palpitations triggered by exercise should be considered cardiac and typically require multiple cardiac tests for thorough evaluation — specifically, ECG, echocardiogram, stress testing and possibly cardiac rhythm monitoring. The importance of a thorough history and physical exam cannot be overstated, and video footage and/or eyewitness accounts, particularly of syncopal events during exercise, can provide critical context.
In preparticipation screening of young athletes, it is particularly important to obtain a thorough family history, as many causes of sudden cardiac arrest or death are inherited in an autosomal dominant pattern. Three-generation family pedigrees are important, as young parents themselves may not have manifested genetic cardiac conditions that may be present and known in grandparents, such as hypertrophic cardiomyopathy or other cardiomyopathies. Cardiac testing for a family history of heart disease should be guided by the family member’s specific cardiac diagnosis and prior cardiac testing. It is important, therefore, to thoroughly gather information, including cardiac testing results, genetic testing results and/or autopsy reports.
Minimizing risk in young athletes
Once cardiac disease is identified in a young athlete, the pediatric cardiologist or practitioner’s role is to educate the athlete, parents and/or guardian of the known activity-related risks and try to minimize risk. It may be prudent through shared decision-making to also involve the competitive athlete’s trainers and/or coaches. Historically, the recommendation was for patients with HCM, long QT syndrome or other related conditions to avoid or limit strenuous physical activity due to the high perceived risk for sudden cardiac arrest or death.
Recent studies evaluating the risk for sudden cardiac arrest or death in athletes have expanded the scope of participants to include both children and adults.
The LIVE-HCM study demonstrated that high-intensity exercise did not increase the cardiac event rate for athletes with HCM. Similarly, research on pediatric and adult athletes with long QT syndrome who received care at experienced centers suggests the absolute risk for sudden cardiac arrest or death is not only low, but also similar between athletes engaging in vigorous and non-vigorous exercise. Such data help to inform shared decision-making conversations with athletes rather than invoke widespread restrictions to exercise. Ongoing registries such as the Outcomes Registry for Cardiac Conditions in Athletes and future research are necessary to develop guidelines of greater applicability to youth athletes with and without cardiac disease.
It is well known that sports participation has both short- and long-term positive impacts for children and adolescents. However, individuals with congenital heart disease generally participate in lower levels of physical activity compared with their peers, despite evidence that regular physical activity leads to improvements in overall exercise capacity, natriuretic peptide levels, quality of life scores, depression scores and self-efficacy scores.
Additionally, the incidence of SCA/D in children with congenital heart disease is relatively rare and often not associated with physical activity, though potential cardiac risks associated with vigorous physical activity may differ based on specific lesions. Given this, it is recommended that shared decision-making be performed based on risk stratification, as this remains the best method for approaching both youth and adult athletes with heart disease.
The role of pediatric sports cardiology experts
All pediatric cardiologists should have a general understanding of the CV changes with exercise and the most recent consensus statements, but the complexity of pediatric sports cardiology supports a role for pediatric sports cardiology experts. These individuals should not see all the athletes in a pediatric cardiology practice but can be a valuable resource for a medical group or region when complicated situations arise. Local pediatric sports cardiologists should know the expected cardiac adaptations with athletic training and how they impact cardiac testing, appropriately select and interpret cardiopulmonary exercise testing results, be up to date with the most recent literature and consensus documents, and have experience in the shared decision-making process.
It is important that the pediatric sports cardiologist is not expected to be an expert in every field of cardiology. Instead, they can work alongside various experts, such as g, HCM experts, long QT experts or anomalous coronary artery origin experts, to assist with the complex decision-making that goes into sports participation and physical activity in individuals with these conditions. They may also have a role in the education of local primary care providers, school systems and community sports systems, particularly in relation to the development and practice of emergency action plans for athletes.
For more information:
English Flack, MD, MS, is associate professor of pediatrics, division of pediatric cardiology at Monroe Carell Jr. Children’s Hospital at Vanderbilt. She is the cardiologist for the Vanderbilt Youth Sports Health Center as well as a team cardiologist for Vanderbilt University Athletics and Nashville SC. Flack can be reached at english.c.flack@vumc.org.
Mason Stevens, MD, is a pediatric resident at the University of Virginia. Stevens can be reached at chn5sc@uvahealth.org.
Mara Weigner, MD, is a pediatric resident at the University of Virginia. Weigner can be reached at mkw3mjn@uvahealth.org.
Peter Dean, MD, FACC, is an associate professor in the division of pediatric cardiology at University of Virginia. He is the medical director of the pediatric exercise stress laboratory and team cardiologist for UVA Athletics. Dean can be reached at pnd8j@uvahealth.org.
Sources/Disclosures
Source:
Expert Submission
References:
- CDC. https://www.cdc.gov/yrbs/results/index.html. Published Oct. 31, 2024. Accessed Aug. 12, 2025.
- Dean PN, et al. Congenit Heart Dis. 2015;doi:10.1111/chd.12221.
- Jortveit J, et al. Eur Heart J. 2016;doi:10.1093/eurheartj/ehv478.
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- NFHS releases first high school sports participation survey in three years. https://nfhs.org/stories/nfhs-releases-first-high-school-sports-participation-survey-in-three-years. Published Oct. 10, 2022. Accessed Aug. 12, 2025.
- Outcomes Registry for Cardiac Conditions in Athletes (ORCCA). https://orccastudy.org/. Accessed Aug. 12, 2025.
- Project Play. https://projectplay.org/state-of-play-2023/participation. Published 2023. Accessed Aug. 12, 2025.
- Ray TD, et al. J Spec Pediatr Nurs. 2011;doi:10.1111/j.1744-6155.2011.00282.x.
Disclosures:
The authors report no relevant financial disclosures.
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