After dinner, I begin to study my schedule for the next day. Among some more common cases, one stands out. I review the attached exams: ECG, MRI. I have no doubt: Here is a case of hypertrophic cardiomyopathy.
The patient is a 17-year-old athlete who is training intensely to compete in triathlons and Ironman races. He has already successfully participated in some events and now intends to participate in a major competition abroad. His father, uncle, and cousin have already been diagnosed with the same condition. What do the family want to know? Will he be able to safely compete? What are the risks for sudden death during exercise?
Although rare, sudden cardiac death during a sports competition generates intense media coverage and scares everyone, including the physicians who treat and evaluate athletes. Sports cardiologists naturally devote much of their attention to the prevention of these events, developing strategies to identify patients at greater risk and generating protocols to increase the chances of quickly resuscitating instances of sudden cardiac arrest — although doing so is hardly feasible in many of the long-duration competitions, such as aquatic marathons, cross-country skiing, Hawaiian canoeing, adventure running, and Ultra/Ironman races. As I review this case, I start to remember …
Athlete Eligibility Recommendations: Marathon, Not Sprint
In 1976, I was studying medicine as a trainee at the exercise physiology laboratory at the Federal University of Rio de Janeiro. I was in the midst of evaluating athletes when I heard the news that a soccer player had been banned and was urged to stop playing the sport because he had an inverted T wave on his ECG. That was the moment I started to get interested in sports cardiology.
Fast forward a few years to 1985 and the publication of the Bethesda consensus on athlete eligibility, led by Jere Mitchell, MD, and Barry Maron, MD. I read and studied the recommendations and kept the printed version in my drawer to consult whenever necessary. As I progressed in my career and gained decades of professional experience, I saw firsthand many cases of athletes or exercisers with suspected or diagnosed cardiac conditions. I was also able to meet some of these leading names in the field, such as Maron, Antonio Pelliccia, MD, and Paul Thompson, MD. Later, we even shared the stage during scientific sessions at several congresses, and I co-authored two American Heart Association (AHA) cardiovascular screening recommendations (for master athletes and children) with these renowned colleagues.
However, at the 2015 Scientific Sessions of American College of Cardiology (ACC), I heard Sharlene Day, MD, speak about training and competition in athletes with hypertrophic cardiomyopathy and was drawn to a new way of analyzing and thinking about these cases. During informal conversations with colleagues — and especially during "jog and talks" with Sharlene along the beaches of Copacabana and Ipanema — I developed an appreciation for a new method of treating patients. My perspective progressively evolved and, in 2016, I organized a joint symposium of the ACC and the Rio de Janeiro Cardiology Society on Exercise and Sports Cardiology. The time for shared decision-making had arrived.
Shared Decision-Making: Bring Patients Into the Huddle
In the present day, I open my computer to the 2025 AHA and ACC scientific statement on participation in competitive sports by athletes with cardiovascular abnormalities. With this latest update, I am pleased to see the new version of the sports classification figure — a significantly improved version that incorporates new evidence based on well-organized registries.
The change in the title of this statement is also substantive. In 1985, we had "Cardiovascular abnormalities in the athlete: recommendations regarding eligibility for competition". Now the title reads "Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities". This version explicitly declares “an emphasis on shared decision-making were integral in the writing of all clinical considerations presented.”
Much like its 1985 predecessor, the document instantly became a defining moment in the field of sports cardiology.
Exercise-Related Death: Know the Score
Sudden deaths in sports— or even during exercise or physical activity — is an extremely rare event. But what exactly does extremely rare mean? During my internship at McMaster University, Geoffrey Norman, PhD, taught me to express probabilities in numbers rather than adjectives. For this purpose, I use my own score, which I call RISKERD (Risk of Exercise-Related Death).
The RISKERD is calculated as the number of zeros or the exponents in the estimated incidence rate of a death. For example, if the estimated incidence rate of a death during participation in a supervised cardiac rehabilitation session is 1 in 100,000 (1/105), the RISKERD score would be 5. If the incidence rate during participation in an elementary school volleyball game is 1 in 10,000,000 (1/107), the score would be 7.
Naturally, the RISKERD for a given sports session or competition is modulated by many variables, including sex, age, clinical conditions, climatic factors, stress, and the use of ergogenic substances or stimulants. These variables can typically adjust the RISKERD score by 1 to 2 points.
On the other hand, mounting evidence tells us individuals who are physically fit and regularly exercise will live longer. Consequently, a lifetime medical recommendation to avoid exercise, sports practice, and competition — especially in young individuals — tends to significantly reduce lifespan and should be carefully reserved for specific cases.
Informative Risk Stratification: Patients Call the Shots
Over the decades, I have changed the way I practice sports cardiology. I've gradually moved from a dogmatic view of "eligible vs not eligible" to the application of shared decision-making, until finally arriving at a new perspective I've named informative risk stratification (IRS).
I continue to thoroughly evaluate the clinical case, considering medical history, physical examination, sports goals, and if possible, a cardiopulmonary exercise test that I personally conduct to estimate the individual’s RISKERD score. In the sequence, I have a consultation with the athlete — and family, if appropriate — during which I explain their stratified risk (RISKERD score) based on the best available evidence.
In discussing the IRS, I carefully listen to the patient's thoughts and feelings and answer their questions posed. What I will not do is dictate an ultimate decision. With my advice, the patient will make the decision that best fits their expectations, interests, and beliefs.
Indeed, most medical specialties already adopt some version of this practice. Physicians acknowledge that all treatment plans come with some risk, and after a collaborative discussion the patient makes an informed decision to determine if they follow medical advice. Whether it's adopting lifestyle changes, taking prescribed medications, undergoing surgery, starting chemotherapy, consenting to an invasive examination, or competing in sports — the decision ultimately lies with the patient.
Why should sports cardiology be different?
