Pre-Race Health Check: Heart Screening for Athletes

Sudden cardiac death in endurance sport is rare — depending on the population and the discipline, roughly 1 in 50,000 to 1 in 200,000 athletes per year. That is exactly why a sports medical check before your first race is the cheapest insurance you can buy: it offers no guarantee, but it does find the few findings you should know about beforehand. This article covers what a pre-participation screening includes, which cut-off values matter, what is normal yet looks alarming — and what a check-up cannot do.

Who should get screened

There is no legal obligation for recreational sport in most countries, including Austria. A sports medical examination still makes sense for almost everyone, just with different urgency. The rule follows your risk profile, not your race calendar.

• Before your first half marathon or marathon: a check with resting and exercise ECG, even if you feel perfectly healthy. The trigger is not the distance but the new peak load over two to five hours.
• Men over 40, women over 50: every 12 to 24 months, and yearly with a family history, smoking, elevated blood lipids, diabetes or high blood pressure. The reason: from around age 35 the cause of rare events shifts from congenital heart disease to coronary artery disease.
• After a break of two years or more: before restarting with intensity. Fitness is gone, and the cardiovascular capacity has to be assessed afresh.
• With warning signs: regardless of age or interval — then you do not wait for the next routine check (see below).
• For races that require medical clearance: many organisers in cycling and mountain sports ask for a certificate, and in Italy an annual sports medical certificate is legally required for competitive athletes.

What the examination includes

A full sports medical examination is more than a stethoscope on the chest. The sensible standard for endurance athletes consists of six building blocks, and not every athlete needs all of them.

• History and family history: previous conditions, medication, sudden deaths of relatives under 50, past fainting or chest symptoms during exertion. This part finds most of the relevant cases.
• Physical examination: blood pressure seated and after exercise, pulse, heart sounds, oedema, spine, joints, foot position.
• Resting ECG: twelve leads. It detects rhythm disorders at rest, conduction abnormalities and hints of structural change — in athletes it produces roughly 10 to 20 percent false positives when old criteria are applied.
• Exercise ECG (ergometry): a staged protocol on a bike or treadmill with increasing wattage, heart rate, blood pressure and ECG under load. This is the core element, because many abnormalities only appear during exercise.
• Blood work: complete blood count, ferritin, inflammatory markers, thyroid, blood lipids, glucose, kidney and liver values, optionally vitamin D and B12. For endurance athletes, iron and thyroid matter most.
• Additional, when indicated: echocardiography (heart ultrasound) for abnormal ECG, murmurs, family history or blood pressure problems; lung function for exercise-induced asthma; performance diagnostics with lactate or spiroergometry when target times and training zones need to be derived.

Which cut-off values matter

Numbers take the fear out of the check. These values appear in almost every sports medical report, and these ranges count as unremarkable.

• Resting blood pressure: below 130/85 mmHg is normal, 130–139/85–89 is high-normal, from 140/90 it counts as hypertension. Important: sports cardiology guidelines accept values up to 139/89 with good exercise tolerance; in competition a break is only required from 140/90. A value above 160/100 always means stop training and get it investigated.
• Blood pressure during exercise: systolic pressure should rise under load — to 180 to 200 mmHg at maximum effort. A falling systolic pressure during exercise is the most important pathological finding and a reason to stop the test.
• Maximum heart rate: you should reach at least 85 percent of the predicted maximum (rule of thumb 208 minus 0.7 × age). Stopping early does not automatically mean a heart problem — often it is the legs or motivation.
• Heart rate recovery: the pulse should drop by more than 12 beats in the first minute after exercise. A slow drop is an independent risk marker and a useful long-term trend value.
• Haemoglobin: men 13.5–17.5 g/dl, women 12.0–16.0 g/dl. Values below 12 or 13 (often tolerated in endurance athletes as "sports anaemia") mean investigate iron first, then build volume.
• Ferritin: for endurance athletes the target range is 30 to 100 ng/ml. Below 30 ng/ml the iron stores are empty even when haemoglobin is still normal — a frequent cause of performance dips that has nothing to do with training.
• TSH: 0.4 to 4.0 mU/l. Both overactive and underactive thyroid change pulse, weight and exercise tolerance markedly; the thyroid is a common incidental finding in endurance athletes.
• Creatine kinase and inflammatory markers: CK is physiologically elevated after hard sessions (often above 500 U/l after a marathon). That is why at least two days should lie between your last hard session and the blood draw.

What is normal yet looks alarming

A regularly training endurance athlete does not have a "normal" heart. The athlete's heart is a physiological adaptation: the left ventricle grows, resting heart rate drops (often below 50, in endurance athletes to 40 to 45), the sinus rhythm can show arrhythmias, and ECGs frequently show findings such as an incomplete right bundle branch block or repolarisation changes in V2 to V4. These count as normal in athletes as long as they appear in an established pattern — from age 35 with a clean history, even the simple two-step workup is sufficient.

This is exactly the problem with pre-participation screening: because many physiological adaptations look like disease findings, there is a substantial rate of false positives. Studies in athlete cohorts show that a screening ECG alone appears abnormal in 1 to 5 percent of a large field, without any relevant disease being present. The consequence: unnecessary follow-up tests, exclusion from competition and, above all, anxiety. So the rule is: with an abnormal finding, do not google it yourself, go to sports cardiology — where the picture is usually differentiated further with echocardiography, Holter ECG and occasionally MRI.

Two warning signs behave differently and are never "normal adaptation". First, fainting during or immediately after exertion. Second, a sudden performance collapse with racing heart out of nowhere, especially when accompanied by dizziness or breathlessness. Anyone with one of these signs should get it clarified by sports medicine immediately and train only easy until then — with no new intensity peaks. Practical guidance on dizziness and circulatory signals is in dizziness when running.

The check before your first marathon

The best time for a sports medical check is 8 to 12 weeks before your goal race — not three days before. In this window the finding still has consequences: an abnormality in the exercise ECG, depleted iron stores, blood pressure that needs controlling — all of that can still be integrated into the build.

A sensible sequence looks like this: first the basic sports medical examination with exercise ECG and blood work, then performance diagnostics (lactate step test or spiroergometry) if training zones need to be derived properly, then a look at teeth, sinuses and vaccination status — underestimated factors for the immune system and tolerance to load. That last point explains why infections in the final race preparation occur more often than chance would allow.

Anyone who translates the results of the exercise test into zones then trains more precisely. Two values serve exactly that purpose: the anaerobic threshold from the lactate test and the heart rate zones. How the two interact and where the limits of heart rate control lie is covered in breathing while running and in heart rate zones in training. Important for anyone tying the check to a target time: the thresholds measured in the test are day values recorded under laboratory conditions — a deviation of a few seconds per kilometre in a race is normal, and the training programme should not be rebuilt on it. The complete multi-month build is described in the 16-week marathon training plan; for orientation beforehand, the weekly volumes per performance level are on the Peakora training glossary.

What the check cannot do

Pre-participation screening has limits, and knowing them helps you place the result correctly.

• It does not detect everything. The sensitivity of the resting ECG for hypertrophic cardiomyopathy — one of the more common causes of events in young athletes — is around 80 percent depending on the subgroup. An unremarkable finding is good news, but not an absolute guarantee.
• It measures the current state, not the training trajectory. The check says nothing about whether you tolerate the load over weeks. Only training management with load history and form values does that — in Peakora through the shared curve of TSS, CTL, ATL and TSB.
• More frequent screening is not better. With a low risk profile and no symptoms, one examination per year buys no extra safety, only false positives. The interval belongs to your risk profile, not your ambition.
• It does not lead to training. The report documents clearance or restriction — the consequence for weekly volume, intensity distribution and recovery is yours to draw, or belongs in a plan that accounts for it.

Warning signs: when to see a doctor immediately

These six signs do not belong in the category of minor niggles but in the category of clarify immediately — regardless of when your last check was.

• Chest pain or pressure as the load increases, especially when it pulls, radiates into the arm or jaw, or disappears again at rest.
• Fainting or near-complete circulatory collapse during or immediately after exertion.
• Irregular racing heart with a sudden onset and sudden end, rather than a steady fast pulse.
• Unusual breathlessness at loads that used to be easy — particularly with coughing or wheezing, which points towards exercise-induced asthma.
• A performance dip lasting two weeks at the same load and sleep: here blood work comes first, decisions about training second — not the other way round. The system is described in overtraining symptoms.
• Recurring dizzy spells when standing up or during easy training: usually harmless, but if they accumulate it is a reason for a resting ECG and longer monitoring.

Sports watch and self-monitoring as a complement

A check every 12 to 24 months says nothing about the other 728 days. Self-monitoring fills that gap: morning resting heart rate, perceived exertion (RPE scale) and recovery. If your morning resting pulse rises by more than 7 beats on three consecutive days, that is no reason to panic, but it is a reason for an easy session instead of a hard one.

Systems with HRV measurement add heart rate variability, and with sufficient measurement quality you can build a useful trend from it. The classification matters: a sports watch detects no structural heart conditions, no exercise ECG findings and no arrhythmias. It complements the sports physician day to day. How reliable each measurement method is, is covered in chest strap versus watch.

Peakora connects both levels: in the recovery monitor, load history, sleep and recovery status combine into a single form value, and the plan reacts when the curve only points downward over a longer period. The sports medical report remains the foundation — the monitor makes sure you do not wait for warning signs day to day, but see them in the trend.

Frequently asked questions about the pre-race check

Is a pre-participation sports screening mandatory?

In most countries there is no legal requirement for recreational athletes, but many race organisers and clubs ask for a medical clearance, and national federations regulate testing for squad athletes. Italy requires an annual certificate even for competitive amateurs.

What does an exercise ECG cost?

As a rough guide, a sports medical examination including an exercise ECG costs between 100 and 300 euros depending on the clinic and the scope. Some health insurers cover part of it on referral, especially when there are concrete symptoms.

How often should I get a sports medical check-up?

Active people over 40 should be checked every 12 to 24 months, and yearly if risk factors are present. Under 35 with no symptoms, an interval of three to five years is enough as long as no warning signs appear.

Can I run a marathon with high blood pressure?

Often yes, provided the blood pressure is well controlled with medication and the exercise test shows no abnormalities. Control is the deciding factor, not avoidance: endurance training lowers blood pressure by about 5 to 10 mmHg in the long run.

Can my sports watch replace a doctor's check?

No. A sports watch measures heart rate, heart rate variability and sleep, but it detects no structural heart conditions and cannot replace an exercise ECG. It complements medical screening day to day, it does not replace it.