The electrocardiogram is the cornerstone of cardiac screening in athletes, young and old. But an ECG has limits. It cannot reliably identify an anomalous coronary artery origin. It gives limited information about the aortic root. It will not clearly show a structurally subtle form of hypertrophic cardiomyopathy in a child whose ECG happens to be near-normal. These are the gaps that echocardiography fills and the new ESC and AEPC consensus statement on paediatric athlete cardiac screening addresses the role of the echo with notable care and nuance.

The headline statement is deliberately measured. A single transthoracic echocardiogram may be appropriate in paediatric athletes to identify high-risk structural cardiac diseases not detectable on ECG. The word "may" is intentional. Unlike the four-star recommendation for history, examination, and ECG, the echo recommendation carries three stars (a strong expert consensus), but acknowledging that the evidence base is less robust and that implementation requires infrastructure and expertise that is not universally available.

What are the conditions the echocardiogram is designed to catch that an ECG might miss? Two stand out. First, anomalous coronary artery origins (congenital variations in where the coronary arteries arise from the aorta) account for approximately 17% of sudden deaths in young American athletes, making them the second most common structural cause. Many of these young people have a completely normal ECG. Second, aortic root dilation, particularly relevant in children with connective tissue disorders such as Marfan or Loeys-Dietz syndrome, can progress silently and is not visible on a heart tracing.

The guidance sets out clear indications for performing an echocardiogram in a young athlete. An abnormal ECG always warrants one. Borderline ECG findings should prompt a case-by-case decision. Symptoms such as unexplained exertional chest pain, palpitations, or syncope are strong indications. An abnormal physical examination, a diastolic murmur, a systolic murmur of grade 2 or above, signs of a connective tissue disorder, or differential blood pressure demands echo evaluation. A family history of sudden cardiac death before the age of 40, or a first-degree relative with cardiomyopathy, also triggers the scan.

Beyond these indications, interpreting the echocardiogram in a young athlete requires specific skills that go beyond standard paediatric or adult cardiology. The athlete's heart produces genuine structural changes (chamber enlargement, mildly increased wall thickness) and distinguishing these from early cardiomyopathy in a child is not straightforward. Absolute measurements are often unhelpful. A left ventricular wall thickness of 10 mm might be meaningless in a 17-year-old elite rower but significant in a 12-year-old recreational swimmer. Z-scores, which adjust measurements against population norms for body size are essential. So is longitudinal follow-up. A heart that appears borderline once may declare itself over two years of serial monitoring.

The consensus statement also highlights more advanced echocardiographic tools. Two-dimensional strain imaging, which measures myocardial deformation rather than just dimensions or ejection fraction, is gaining traction as a way to detect early left and right ventricular dysfunction in cardiomyopathies before conventional measurements become abnormal. In a specialist hands, this adds meaningful diagnostic sensitivity.

One point the document makes that deserves emphasis: if you are going to offer echocardiography as part of a screening programme, you need the infrastructure to handle what you find. A borderline result in a 13-year-old creates an obligation to the child, to the parents, to the sport for timely, expert follow-up. Screening without that pathway is not safer care. It is anxiety without resolution.

Dr. Alessandro Giardini provides private sport cardiology assessments and screenings in his London clinics.

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Author: Dr. Alessandro Giardini, MD, PhD, Consultant Paediatric Cardiologist

Written 08/06/2026