Preparticipation Cardiac Evaluation in Children and Adolescents: International Guidelines and Practical Considerations

Sudden cardiac death (SCD) in children and adolescents participating in sports, although rare, represents a devastating event with significant clinical and social implications. Preparticipation cardiac screening has been proposed as a preventive strategy to identify individuals at risk before they develop life-threatening arrhythmias or cardiac arrest during exercise. Current evidence demonstrates that the leading causes of SCD in young athletes include hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, anomalous coronary arteries, myocarditis, and inherited channelopathies. International guidelines provide divergent recommendations regarding screening strategies. The American Heart Association and the American College of Cardiology advocate a focused history and physical examination without the routine use of electrocardiography (ECG), whereas the European Society of Cardiology endorses the inclusion of a standard 12-lead ECG. More recent consensus statements, such as those from the International Olympic Committee and Fédération Internationale de Football Association, aim to harmonize approaches across countries. While ECG has been shown to increase sensitivity for detecting silent cardiac conditions, concerns remain about false positives, limited specificity, cost-effectiveness, and the need for experienced interpretation. Emerging strategies, including advanced imaging modalities, genetic testing in selected populations, and artificial intelligence-assisted ECG analysis, may enhance risk stratification in the future. This review summarizes the current evidence, highlights key controversies, and discusses future perspectives on preparticipation cardiac screening in children and adolescents involved in sports.