Prof Viviana Maestrini, University of Rome, Italy
Prof Daniele Andreini, University of Milan, Italy
What is the reason for and aim of the publication?
The number of people participating in sport at a high level is increasing over time, and these individuals require specific cardiovascular attention, as athletes represent a population that differs substantially from non-athletic individuals. Cardiovascular evaluation of athletes is important to reduce the risk of sport-related sudden cardiac arrest and sudden cardiac death, but it is particularly challenging because physiological adaptations to intensive exercise may overlap with features of early cardiovascular disease. The key clinical task is therefore not simply to detect abnormalities, but to distinguish physiological cardiac remodelling from underlying pathology, while avoiding both missed diagnoses and unnecessary restriction from sport.
Although cardiovascular imaging recommendations for athletes have previously been published, guidance has focused mainly on echocardiography. Specific recommendations regarding the indications, acquisition protocols, and interpretation of cardiovascular magnetic resonance (CMR), cardiac computed tomography (CCT), and nuclear imaging in athletes were therefore still needed.
This EAPC/EACVI clinical consensus statement provides a practical multimodality framework for the appropriate use of advanced cardiovascular imaging in athletes. It addresses when these techniques should be used, how examinations should be performed and, importantly, how findings should be interpreted in the context of exercise-induced cardiac adaptation. The ultimate aim is to improve diagnostic accuracy and risk stratification, protecting athletes from cardiovascular events while, at the same time, avoiding inappropriate restriction from sport.
What are the most important take-home messages?
- Advanced cardiovascular imaging should be requested when clinically indicated.
CMR, CCT and nuclear imaging are second-line tools and should be selected according to the specific clinical question. CMR is particularly valuable for cardiac morphology, ventricular function and myocardial tissue characterization; CCT provides excellent assessment of coronary anatomy, congenital coronary anomalies and atherosclerotic disease; while functional imaging plays a key role when myocardial ischaemia or inflammation needs to be assessed.
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Athlete-specific interpretation is essential.
The same imaging finding may have a very different significance in an athlete and in a sedentary individual. Interpretation should therefore consider age, sex, ethnicity, sporting discipline, training intensity and volume, and training history. Balanced biventricular dilatation, increased left ventricle mass or a low-normal ejection fraction may represent physiological adaptation, whereas disproportionate remodelling, regional abnormalities or pathological patterns of myocardial fibrosis should raise suspicion of disease. Standardized acquisition and athlete-specific interpretation are essential to avoid overdiagnosis and unnecessary restriction from sport.
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Imaging findings must always be integrated into the overall clinical context.
Advanced imaging should never be interpreted in isolation. Symptoms, family history, ECG findings, ventricular arrhythmias, exercise testing and first-line imaging all contribute to defining the pre-test probability of disease and the significance of imaging findings. This integrated approach is particularly important in athletes, because an imaging diagnosis may have major implications for eligibility, performance and career.
What are the challenges in practical implementation – and possible solutions?
One of the main challenges is the lack of robust athlete-specific reference values across different sporting disciplines and levels of training, which has a direct impact on the accurate interpretation of imaging findings. This is particularly relevant when evaluating ventricular dilatation, hypertrophy, or mildly reduced resting systolic function, where physiological adaptation may overlap with disease. Imaging findings should not be interpreted using reference ranges derived from sedentary populations, but rather in the context of the major determinants of cardiac remodelling, including sex, age, ethnicity, sporting discipline, and training volume and intensity. Developing robust reference values that account for these determinants should therefore be a major priority for future research.
A second challenge is technical standardization. Athletes may present specific acquisition issues, including marked sinus bradycardia, low body fat, and different contrast kinetics, which can affect CMR acquisition and tissue characterization. Protocols may therefore require specific adaptations while maintaining high image quality, particularly for LGE assessment. In CCT, especially in young athletes, radiation exposure should be minimized through contemporary scanners and optimized acquisition protocols.
Finally, the clinical indication must be clearly defined before advanced imaging is requested. Close communication between sports cardiologists and cardiovascular imagers, together with standardized acquisition protocols and reporting and, when appropriate, referral to centres with specific expertise, can help reduce false-positive findings and unnecessary investigations. This is particularly important in athletes, because equivocal or incorrectly interpreted findings may have major implications for sports eligibility and, in professional athletes, for their career.
Which issues still need to be tackled that are not yet addressed by the paper?
The most important unresolved issue is the lack of robust athlete-specific reference datasets. Available CMR reference values are still largely derived from selected populations, with female athletes, adolescents, non-Caucasian athletes, and athletes from different sporting disciplines remaining underrepresented. Moreover, current reference ranges do not adequately account for differences in training volume, intensity, and lifetime exposure. Large, multicentre studies across diverse athletic populations are therefore needed to establish more reliable and clinically applicable reference values.
A second major gap concerns the clinical and prognostic significance of subtle imaging abnormalities, particularly myocardial fibrosis. Minor LGE patterns, mapping abnormalities, and other subtle phenotypes may be detected in otherwise healthy athletes, but their long-term significance remains uncertain. Prospective multicentre studies with long-term follow-up are needed.
Finally, more evidence is needed to determine whether imaging-based strategies translate into improved clinical outcomes. For example, although CACS and CCTA can improve cardiovascular risk stratification and characterize coronary atherosclerosis in master athletes, there is currently no evidence that their use in primary prevention reduces sudden cardiac death or cardiovascular events in athletes.
What further developments on the topic are emerging?
The future needs to move towards a more individualized, multimodality approach, integrating imaging findings with the clinical phenotype, exercise testing, and other markers of cardiovascular risk. The challenge will be to take advantage of increasingly sensitive imaging technologies without misinterpreting physiological adaptations or clinically irrelevant abnormalities as disease.
Artificial intelligence may further enhance our ability to identify subtle abnormalities and detect cardiovascular disease at an earlier stage, as well as improve image analysis and interpretation. However, technology should support rather than replace clinical judgement. The athlete’s clinical context must remain central to the interpretation of any imaging finding.
Ultimately, the goal should remain the precision: identifying athletes who are truly at risk while allowing those with physiological cardiac adaptation to continue exercising safely.
Indications, protocols, and interpretation of cardiovascular imaging for the evaluation and management of athletes
Maestrini V, Gati S, D'Ascenzi F et al. Indications, protocols, and interpretation of cardiovascular imaging for the evaluation and management of athletes: a clinical consensus statement of the European Association of Preventive Cardiology (EAPC) and the European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology (ESC), Part 2: Cardiovascular magnetic resonance, cardiac CT, and nuclear imaging. Eur J Prev Cardiol. Published online June 23, 2026. https://doi.org/10.1093/ehjci/jeag060
