From Preparticipation Screening to Diagnosis: Long-Term Outcomes of Athletes with Ventricular Repolarization Abnormalities and Normal Echocardiography

Background/Objectives: Ventricular repolarization abnormalities (VRA) represent a grey area in athlete screening: some patterns are physiological, while others are precursors to heart disease. Objective: to clarify the natural history of VRA and the associated factors of structural diagnosis. Methods: Retrospective observational single-center study of athletes with resting or stress VRA at the first evaluation, with normal echocardiography; minimum follow-up of 2 years. Clinical data, resting and stress ECG, echocardiography, and selective advanced imaging throughout follow-up were collected. Primary outcome: cardiovascular diagnosis at follow-up; time-to-event analysis and associations between ECG characteristics and diagnosis. Results: Fifty-three athletes (mean age 22.2 ± 9.2 years; 92.5% male) were included; 60.4% had resting VRA, and 100% had exercise-induced VRA at baseline. Over 7.3 ± 4.5 years, 28/53 (52.8%) received a diagnosis; median time-to-detection was 7.0 years (95% CI 6.0–not reached); RMST10 was 6.7 years (95% CI 5.7–7.7). Diagnoses included hypertrophic cardiomyopathy (24.5%), non-ischaemic left-ventricular scar (11.3%), myocardial bridging (7.5%), hypertensive remodelling (5.7%), coronary anomaly (1.9%), and ventricular pre-excitation (1.9%). Persistence of resting VRA from baseline to follow-up was more frequent in athletes with a final diagnosis (p = 0.01), whereas topography and exercise-induced abnormalities did not discriminate groups. Advanced imaging contributed substantially to case ascertainment. No major adverse cardiovascular events have been identified throughout follow-up. Conclusions: In athletes with screening-detected VRA and normal echocardiography, persistence of resting VRA was associated with higher detection of a cardiovascular diagnosis, while exercise-induced changes alone show limited diagnostic yield. The long median time-to-detection supports prolonged, pre-planned surveillance, with priority for advanced imaging in profiles with persistent abnormalities. These findings align with a risk-adapted, personalized management strategy in sports cardiology.