Cardiovascular Risk in Recreational Athletes: The Hidden Gap in Preventive Screening

Why physically active individuals are often overlooked in cardiovascular risk assessment

In my clinical practice, one pattern has become increasingly clear: many physically active individuals assume they are at low cardiovascular risk, but this is not always the case.

Over the past years, I have evaluated patients who train consistently, follow structured routines, and are deeply committed to what they consider a healthy lifestyle. They exercise regularly, eat well, and often push their limits in search of better performance.

Yet, when we look deeper, a different picture sometimes emerges.

I have seen individuals with elevated blood pressure, early signs of coronary disease, or abnormal cardiovascular responses to exercise, despite having no symptoms and no prior diagnosis. In many of these cases, the perception of being “fit” created a false sense of security.

This is not an isolated observation. It reflects a broader and often overlooked gap in preventive cardiology.

The illusion of safety

There is a widespread assumption that regular exercise is enough to protect against cardiovascular disease. While physical activity is strongly associated with long-term health benefits, it does not eliminate underlying risk, especially when proper evaluation is not performed.

Sudden cardiac events during exercise, although relatively uncommon, are well documented and frequently occur in individuals with previously undiagnosed conditions. Scientific statements from the American Heart Association highlight that structural or electrical heart diseases can remain silent until triggered by physical exertion.

In other words, the absence of symptoms does not necessarily mean the absence of risk.

What I see in practice

A common scenario in my office involves individuals who decide to “take their health seriously” and begin high-intensity training. They sign up for endurance races, CrossFit programs, or structured training routines, often without any prior cardiovascular assessment.

In several cases, I have identified:

• previously undiagnosed hypertension
• abnormal findings during exercise testing
• symptoms that had been ignored or interpreted as “normal fatigue”

These findings are more common than most people expect.

Research published in Circulation (Maron et al., 2016) shows that in individuals over the age of 35, the leading cause of exercise-related cardiac events is coronary artery disease, often asymptomatic until triggered by exertion.

This is particularly relevant because it shifts the focus away from rare genetic conditions and toward more common, acquired risk factors.

Recreational athletes: the overlooked population

Much of the discussion around cardiovascular screening has traditionally focused on elite or competitive athletes. However, the population that concerns me most in practice is different.

It is composed of recreational athletes, individuals who:

• are in their 30s, 40s, or 50s
• return to exercise after long periods of inactivity
• rapidly increase training intensity
• engage in high-demand fitness routines without medical supervision

This group represents a large and growing segment of the population.

According to the European Society of Cardiology, cardiovascular risk in adult athletes is more closely related to acquired conditions, such as atherosclerosis, rather than inherited cardiomyopathies. This requires a different and more individualized approach to screening.

Exercise as a trigger, not the cause

This is an important distinction I often emphasize with my patients.

Exercise itself is not the problem.

In most cases, it acts as a physiological trigger in individuals who already have an underlying condition. High-intensity effort increases heart rate, blood pressure, and myocardial demand. If the cardiovascular system is not adequately prepared, this stress can precipitate adverse events.

These may include arrhythmias, ischemic episodes, or, in rare situations, sudden cardiac arrest.

Understanding this mechanism is essential. It shifts the conversation from “exercise is dangerous” to “exercise must be aligned with individual cardiovascular conditions.”

The gap in preventive screening

Despite the growing number of physically active individuals, structured cardiovascular screening is not routinely performed in recreational athletes.

Even when medical evaluations take place, they are often:

• generic
• not exercise-oriented
• not adapted to the individual’s training intensity

In my experience, this is where the real gap lies.

Guidelines from the American College of Cardiology recommend individualized assessment for those engaging in moderate to high-intensity exercise. However, outside organized sports environments, this is rarely implemented in a consistent way.

As a result, there is a mismatch between actual risk and perceived safety.

What effective evaluation should look like

Preventive cardiology in physically active individuals should not be reduced to a general check-up.

It requires a targeted approach, which may include:

• detailed clinical history, including training patterns
• assessment of cardiovascular risk factors
• resting electrocardiogram
• exercise testing when indicated
• additional imaging in selected cases

The goal is not to create barriers to exercise, but to ensure that individuals are training within a safe physiological range.

In practice, even simple adjustments based on proper evaluation can significantly improve both safety and performance.

A broader perspective

This is no longer just an individual concern. It is a population-level issue.

We are witnessing a global increase in people engaging in high-intensity physical activity. This is a positive shift, but it also brings new challenges.

Encouraging exercise without emphasizing safe participation creates an incomplete preventive strategy.

Improving cardiovascular screening in recreational athletes has the potential to:

• reduce preventable cardiac events
• improve long-term health outcomes
• optimize the benefits of physical activity

From a public health perspective, this is a relevant and necessary discussion.

Final thought

In clinical practice, one lesson has become very clear to me: feeling healthy is not the same as being risk-free.

Many physically active individuals operate under the assumption that their lifestyle protects them from cardiovascular disease. In reality, risk is often present but not identified.

Exercise remains one of the most powerful tools for health.

But like any powerful tool, it requires awareness, guidance, and appropriate evaluation.

Because in this population, risk is not absent.

It is simply not being looked for.

About the Author

Joyce Andrade, MD, is a cardiologist with over 15 years of clinical experience, focused on preventive cardiology and cardiovascular safety in physically active populations. Her work centers on bridging the gap between exercise performance and cardiovascular risk awareness, particularly among recreational athletes.

References

• Maron BJ, Udelson JE, Bonow RO, et al. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities. Circulation. 2015;132(22):e273–e280.
• Maron BJ, Haas TS, Ahluwalia A, et al. Incidence and Causes of Sudden Death in U.S. College Athletes. Journal of the American College of Cardiology. 2014;63(16):1636–1643.
• Harmon KG, Asif IM, Maleszewski JJ, et al. Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in NCAA Athletes. Circulation. 2015;132(1):10–19.
• Pelliccia A, Sharma S, Gati S, et al. 2020 ESC Guidelines on Sports Cardiology. European Heart Journal. 2021;42(1):17–96.
• Franklin BA, Thompson PD, Al-Zaiti SS, et al. Exercise-Related Acute Cardiovascular Events. Circulation. 2020;141(13):e705–e736.