Sports Cardiology: Advances in Diagnosing, Treating the Most Athletic Among Us

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February 23, 2022


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Sports cardiology is advancing quite rapidly, covering the specialized care of both professional and amateur athletes — and the very athletic person who is absolutely committed to running, cycling or other physically challenging and recurring activity.

This field involves athletes and very active individuals with known or previously undiagnosed cardiovascular conditions. It incorporates many of the routine cardiac testing that everyone at risk may face, such as electrocardiograms to assess the heart’s electrical system, echocardiogram or magnetic resonance imaging (MRI) to look for structural heart disease.


Eli Friedman, M.D., medical director of sports cardiology at Miami Cardiac & Vascular Institute.

The challenges of this medical specialty are well known to Eli Friedman, M.D., medical director of sports cardiology at Miami Cardiac & Vascular Institute, which is spearheading programs to help diagnose or treat cardiovascular conditions in athletes across South Florida, and help train the athletes and their coaches in proper CPR techniques.

The Institute is also assisting athletic programs with AEDs (automated external defibrillators), devices that can monitor a person who is in cardiac arrest and deliver a shock to the heart to help regain a normal heart rhythm. That’s because athletes, just like those who are not active, can be at risk for sudden cardiac arrest.

The field of sports cardiology is still absorbing much data, at both the local and national levels, to fine-tune the diagnosis and treatment of cardiovascular conditions in athletes of all types.

“We are trying understand the maladaptive mechanisms to help athletes continue to perform at the level they want,” explains Dr. Friedman. “There are many questions that need comprehensive answers. For example: Is somebody who runs seven marathons every year going to be unhealthy, compared to a person who runs one marathon per year? We generally think the answer is no on that, but we’re still accumulating data. Nonetheless, there are certain health conditions, namely atrial fibrillation in men, which can arise as a result of being in sport for really long periods of time.”

Another common question: Can we push athletes out further with certain types of heart disease, versus people who aren’t athletic?

“Maybe we can push athletes further in some respects,” says Dr. Friedman. “But there are situations when we should hold an athlete back and treat him or her in a different manner than we would somebody else who is non-athletic. For example, stable coronary artery disease may be fine for some, but there’s no such thing as stable coronary artery disease in someone who wants to train intensely.”

Who Exactly is an Athlete?

The common misconception out there is that sports cardiology applies only to professional athletes, or those in college or training for track and field events, for example, at the amateur level. The reality is that the field applies to those who take regular exercise or physical activity to a much more intense and deeper level than those who exercise regularly to stay fit, meeting the recommended guidelines.

The U.S. government and the American Heart Association recommend at least 150 minutes per week of moderate-intensity aerobic activity, or 75 minutes per week of vigorous aerobic activity — or a

combination of both, preferably spread throughout the week. Add moderate- to high-intensity muscle-strengthening activity (such as resistance or weights) on at least 2 days per week, the guidance states.

“I smile when someone says they aren’t athletes,” says Dr. Friedman. “That’s something that comes up all the time: ‘Well, I’m not an athlete, but I run two marathons a year and I train five days a week.’ But, yes, you are an athlete at that point. Basically, an athlete to me is to anyone who exercises or trains habitually, and to whom exercise is an integral part of their life. They want to be active and want to do so in a healthy and safe way.”

While a key segment of sports cardiology is focused on college or professional athletes, most patients are not professional athletes, but just as committed to their goals as the pros are.

“The vast majority is going to be those over the age of 35, who exercise habitually and develop symptoms, or have established cardiovascular disease and want to continue to train and perform at the levels they’re comfortable with,” says Dr. Friedman.

Determining Who’s at Risk

Regular exercise has been proven to protect individuals against the development of atherosclerotic disease — the buildup of plaque in artery walls. However, much like the general population, coronary artery disease remains a common problem, even among athletic patients. Studies indicate that atherosclerotic disease is the most common cause of sudden cardiac death in those over the age of 35 years.

Dr. Friedman has developed specialized approaches to cardiovascular care for athletes and those in physically-demanding fields like first responders. Some may have been at risk for heart issues from birth and not know it.

“So, there can definitely be genetic predispositions where somebody’s got a terrible family history of obstructive coronary disease — and bypass and stents,” explains Dr. Friedman. ” And that’s where my favorite saying comes in: ‘You can’t outrun your genes. No matter how many miles you log or how healthy you eat — genetic predispositions may catch up to you.”

And then there are those who exercise intensely but don’t follow other key health habits, like proper nutrition and staying away from vices that include smoking and drinking. “There are lots of people who exercise like crazy, but eat terribly or have smoked or drink too much alcohol,” he says.

There are many risk factors to consider for athletes. Adds Dr. Friedman: “It’s definitely a multifactorial field of cardiology, and we do our best to get into the weeds with everybody and try to figure out who is at risk and use all the testing we have to mitigate that risk.”

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