Cardiovascular Risk in Athletes: Preparticipation Screening, Arrhythmic Stratification, Sudden Cardiac Death Prevention, and Perioperative Management

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Abstract
Arrhythmias and sudden cardiac death represent major challenges in sports cardiology because they may occur in apparently healthy athletes and may be related to structural heart disease, inherited channelopathies, coronary abnormalities, myocarditis, or other arrhythmogenic substrates. This study analyzed the principal factors associated with sudden cardiac death in athletes, with emphasis on cardiovascular preparticipation evaluation, electrocardiographic interpretation, characterization of ventricular arrhythmias, and perioperative cardiovascular management. An integrative review and analytical synthesis of clinical guidelines, consensus statements, epidemiological studies, systematic reviews, and relevant observational investigations was performed using evidence from recognized scientific databases and international cardiovascular societies. The findings demonstrated that sudden cardiac death is uncommon overall but is heterogeneously distributed, with higher incidence reported in specific groups such as male athletes, Black athletes, and Division I male basketball players. Hypertrophic cardiomyopathy, congenital coronary artery anomalies, myocarditis, arrhythmogenic cardiomyopathy, and inherited electrical disorders were identified among the principal underlying conditions. Athlete-specific electrocardiographic criteria reduced abnormal classifications while preserving the detection of clinically significant cardiovascular disease. The analysis of ventricular ectopy showed that morphology, complexity, exercise response, symptoms, and the presence of structural abnormalities are more clinically informative than arrhythmic burden alone. In the perioperative setting, high functional capacity does not eliminate cardiovascular risk, particularly in athletes with known or suspected arrhythmogenic substrates. Electrolyte disturbances, autonomic fluctuations, anesthetic agents, hypoxemia, hemodynamic changes, and surgical stress may facilitate perioperative rhythm disturbances. The evidence supports an integrated and individualized strategy combining preparticipation screening, targeted diagnostic testing, arrhythmic risk stratification, shared decision-making, and perioperative planning. This approach may improve the identification of high-risk athletes while avoiding unnecessary restrictions and promoting safer participation in sport and surgical care.