Heart Screening Before You Start Training: What Is Worth Checking

Sudden cardiac events during exercise are rare, but they are devastating and often affect people who appeared perfectly healthy. A short medical review before you start a new or much harder training programme can pick up a proportion of hidden problems. Our editorial team explains who should be screened, which tests are used and what their limitations are.

Why screening is discussed at all

Regular exercise lowers cardiovascular risk over a lifetime, and that benefit is not in question. The paradox is that vigorous exertion can briefly raise the risk of an event in someone with an undiagnosed heart condition. Screening aims to find those people before they push themselves to the limit.

In young athletes the causes are usually structural or electrical conditions that are often inherited: hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, coronary artery anomalies, and channelopathies such as long QT or Brugada syndrome. In UK pathology series, a substantial share of cases is also found to have a structurally normal heart.

In people over about 35, the picture changes. Coronary artery disease becomes the dominant cause of exercise-related cardiac events, and the classic risk factors such as smoking, high blood pressure, raised cholesterol, diabetes and family history become central to any assessment.

Because each age group has different risks, there is no single test that suits everyone. A sensible plan combines a structured questionnaire, a physical examination and, in selected people, an electrocardiogram or further investigations.

What a basic assessment includes

For most adults starting recreational exercise, the first step is a validated questionnaire. The PAR-Q+ is widely used by UK gyms and personal trainers; a "yes" to any of its core questions is a prompt to speak to a GP or other qualified professional before increasing intensity.

A clinical assessment then looks at personal symptoms, family history and a physical examination. American Heart Association recommendations list a set of history and examination elements, including chest pain on exertion, unexplained fainting, a heart murmur and a family history of sudden death before the age of 50.

1. chest pain, pressure or tightness during exercise;
2. fainting or near-fainting, especially during or straight after exertion;
3. palpitations or a racing heartbeat out of proportion to effort;
4. unusual breathlessness compared with peers;
5. a close relative who died suddenly and unexpectedly before 50, or who has a known inherited heart condition.

Blood pressure measurement is simple and often overlooked. High blood pressure is common, usually silent and highly relevant to anyone planning heavy resistance training, where pressure rises sharply during lifts. A reading at a pharmacy or GP surgery is a good starting point.

Body weight, waist circumference and a simple cholesterol and glucose check add useful context. In England, the NHS Health Check offered to adults aged 40 to 74 covers many of these measures and is a sensible step for anyone returning to exercise after many years away.

The 12-lead ECG and its role

European practice, reflected in the European Society of Cardiology guidance, favours adding a resting 12-lead ECG to history and examination for competitive athletes. The ECG can reveal patterns suggestive of cardiomyopathy, pre-excitation (Wolff-Parkinson-White) and several channelopathies that a stethoscope will miss.

Interpreting an athlete's ECG requires care. Regular training causes normal adaptations, such as a slow heart rate and higher voltage, that can look alarming to the untrained eye. The 2017 International Criteria by Drezner and colleagues set out which findings are normal in athletes and which need further tests.

In the UK, there is no national programme of mandatory ECG screening. Professional football and some other sports run their own programmes, and the charity Cardiac Risk in the Young offers subsidised screening for people aged 14 to 35. Many recreational exercisers will never have had an ECG.

A long-term study of more than 11,000 adolescent footballers screened by the Football Association, published by Malhotra and colleagues in 2018, illustrates both value and limits. Screening identified a number of serious conditions, yet some deaths still occurred among players whose screening had been normal.

Further tests: when they are needed

If history, examination or ECG raise a concern, a cardiologist may request additional investigations. These are not routine for everyone; they are targeted at a specific question. The table below gives an overview of what each test is designed to show.

For adults over 35 with several risk factors, an exercise test or coronary imaging may be more useful than a resting ECG. The ESC 2020 sports cardiology guidelines recommend tailoring such tests to the overall risk profile rather than applying them to everyone.

Doping and some performance-enhancing drugs deserve a mention here. Anabolic steroids and stimulants are linked with high blood pressure, adverse lipid changes, heart muscle thickening and arrhythmias. Anyone with past or current use should be honest with the clinician, because it changes how test results are interpreted.

Recent illness also matters. Myocarditis after a viral infection, including COVID-19, is an uncommon but recognised cause of exercise-related arrhythmia. Current guidance advises against intense exercise while you have a fever or systemic symptoms, and a medical review if chest pain or palpitations persist.

Limits of screening and everyday safety measures

No screening programme catches everything. Some conditions do not show on a resting ECG, others develop after a normal test, and false positives can lead to anxiety, extra tests and, occasionally, unnecessary disqualification from sport. Screening reduces risk; it does not remove it.

For that reason, symptom awareness is just as important as any single test. Chest pain, fainting during exercise or palpitations with dizziness should never be "trained through". Stop, seek medical advice, and do not resume hard sessions until you have been assessed.

Preparedness saves lives. Survival from sudden cardiac arrest depends on immediate CPR and early defibrillation. Many UK gyms, clubs and public places now have automated external defibrillators, and the national defibrillator network, The Circuit, lists their locations for ambulance services.

Learning basic life support is something every training partner, coach and gym member can do. Short courses run by charities and first-aid organisations take only a few hours and give confidence to act within the first critical minutes.

Conclusions of the editorial team

For most healthy adults, a validated questionnaire, a blood pressure check and honest attention to symptoms are an adequate starting point. Anyone who answers yes to warning questions should see a doctor before increasing intensity.

Competitive athletes, and young people with a family history of sudden death or inherited heart conditions, benefit from a structured assessment that includes a 12-lead ECG read by someone familiar with athlete-specific criteria.

Older beginners with risk factors need a different focus: coronary disease rather than inherited conditions. Here, exercise testing or imaging chosen by a clinician is more informative than a resting ECG alone.

Related reading from our editorial team includes guides to blood pressure and strength training, warning signs of overtraining, and how stimulant-based pre-workout products affect heart rate and rhythm.

References

1. Pelliccia A, Sharma S, Gati S, et al. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J. 2021;42(1):17–96.
2. Corrado D, Pelliccia A, Bjørnstad HH, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Eur Heart J. 2005;26(5):516–524.
3. Drezner JA, Sharma S, Baggish A, et al. International criteria for electrocardiographic interpretation in athletes: consensus statement. Br J Sports Med. 2017;51(9):704–731.
4. Malhotra A, Dhutia H, Finocchiaro G, et al. Outcomes of cardiac screening in adolescent soccer players. N Engl J Med. 2018;379(6):524–534.
5. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update. Circulation. 2007;115(12):1643–1655.
6. Warburton DER, Jamnik VK, Bredin SSD, Gledhill N. The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and electronic Physical Activity Readiness Medical Examination (ePARmed-X+). Health Fit J Can. 2011;4(2):3–23.