Primary care providers can identify cardiac risk during sports physicals. Learn key red flags and when to refer young athletes to cardiology.

Published: January 22, 2026

Sports preparticipation exams are critical opportunities to identify young athletes at risk for sudden cardiac arrest, which is the leading cause of death in young athletes during sports.

While sudden cardiac arrest in children is less common than in adults (3 to 8 per 100,000, compared with 52 per 100,000), the stakes remain high when screening student-athletes.

Children of all ages, even though they appear healthy, can have unknown, underlying risk factors that can place them at risk for sudden cardiac arrest. Warning signs are present in 20% to 40% of sudden cardiac arrest events, but often go ignored — which makes comprehensive screening essential.

Red flags during examinations

According to Adam M. Skaff, M.D., pediatric cardiologist with Norton Children’s Heart Institute, affiliated with UofL School of Medicine, primary care providers’ established relationship and comprehensive knowledge of the patient’s history ideally positions them for this type of cardiac screening.

“These screens should be performed at the patient’s medical home,” Dr. Skaff said. “The primary care provider is the person who knows the patient and their family the most.”

During examination, providers should always assess for:

• Pathologic murmurs
• High blood pressure (can cause exertional chest pain)
• Stigmata of Marfan syndrome
• Exertional symptoms
• Family history
• Automatic referral criteria

Exertional symptoms

Some of the most concerning symptoms are those triggered or worsened by exercise.

Exertional symptoms include:

• Syncope or near-syncope during or after physical activity
• Chest pain, discomfort or pressure with exertion
• Palpitations (heart racing or fluttering) during exercise
• Unexplained shortness of breath with activity

“If exercise makes it worse, those are things that are typically red flags for me,” Dr. Skaff said. “Symptoms at rest sometimes can be related to underlying cardiac abnormalities, but by far and away, those are the ones that are more related to stress, anxiety or other types of factors.”

Family history

Providers should ensure they are asking the right questions while taking a thorough family history of a patient.

Any of the following can signal potential family history red flags for cardiac risk:

• Sudden cardiac death before age 35
• Specific triggers like drowning (possibly long QT Type 1) or unexplained single-car accidents (potential arrhythmia at the wheel)
• Cardiomyopathies (hypertrophic, dilated, arrhythmogenic right ventricular, left ventricular noncompaction)
• Channelopathies (long QT, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia)
• Family members with pacemakers or defibrillators at young ages

When to refer to cardiology

The American Heart Association does not recommend routine electrocardiogram (ECG) for all athletes. However, any red flag symptom warrants cardiology evaluation. If ECG is obtained before referral, ensure interpretation by someone trained in pediatric cardiology, as normal variants in young athletes can be misread as pathology, according to Dr. Skaff.

“When in doubt, refer,” he said “Your vigilance during sports physicals can save lives.”

Additional symptoms and conditions, listed below, are considered automatic referral criteria.

Automatic referral criteria

These conditions warrant immediate cardiology referral:

• Known congenital heart disease (clearance should come from the patient’s cardiologist, not primary care provider)
• History of myocarditis (requires minimum six months’ exercise restriction and cardiology clearance)
• Kawasaki disease with moderate or large coronary aneurysms
• Previous cardiac surgery or known arrhythmia disorders
• Wolff-Parkinson-White syndrome, especially if symptomatic

Pay attention to noncardiac factors

Providers should not overlook noncardiac factors that can mimic cardiac symptoms. Screen for caffeine overuse, as energy drinks have caused increasing emergency department visits for palpitations and chest pain in young people. Also address mental health, as anxiety can manifest as cardiac-appearing symptoms, particularly at rest.