Programmed ventricular stimulation for risk stratification in symptomatic athletes with nonischemic left ventricular scar and preserved ejection fraction.
Sciarra L, Ricci F, et al. • Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology • 2026
In symptomatic athletes with non-ischaemic LV scar and preserved LVEF, inducibility at EPS identifies a subgroup at higher risk of major arrhythmic events, whereas non-inducibility is associated with a low event rate.
Key Findings
Results
Nearly one-third of symptomatic athletes with non-ischaemic LV scar and preserved ejection fraction were inducible at electrophysiological study.
72 consecutive athletes were prospectively enrolled (mean age 48.9 ± 13.1 years; 66.7% male)
All had documented non-ischaemic LV scar, preserved LVEF (≥50%), and arrhythmic symptoms (tachycardic palpitations, syncope/presyncope, and/or exercise-related ventricular arrhythmias)
23 athletes (31.9%) were inducible (EPS+) and 49 (68.1%) were non-inducible (EPS-)
Inducibility was defined as sustained ventricular arrhythmias during programmed ventricular stimulation
Results
Inducible athletes had significantly longer QRS duration compared to non-inducible athletes.
QRS duration was 104.6 ± 15.2 ms in inducible athletes vs. 95.5 ± 14.3 ms in non-inducible athletes (P = 0.019)
Baseline characteristics were otherwise largely comparable between groups
QRS duration was the only noted statistically significant baseline difference between groups
Results
Inducible athletes experienced a substantially higher rate of major arrhythmic events compared to non-inducible athletes during follow-up.
During a median follow-up of 42 months, 11 major arrhythmic events (MAE) occurred in total
Nine events occurred among the 23 inducible athletes, consisting of sustained ventricular arrhythmias (monomorphic VT, polymorphic VT, or ventricular fibrillation) successfully terminated by appropriate ICD therapy
Two MAEs occurred among the 49 non-inducible athletes, requiring successful resuscitation followed by ICD implantation
No arrhythmic deaths occurred during follow-up
Event-free survival at 50 months was 40.6% in inducible athletes and 95.9% in non-inducible athletes (log-rank P < 0.001)
Results
All inducible athletes received ICD implantation, while non-inducible athletes were managed with implantable loop recorders.
All 23 inducible athletes underwent ICD implantation: 18 received transvenous devices and 5 received subcutaneous devices
16 non-inducible athletes received an implantable loop recorder for ongoing monitoring
This management strategy reflected the risk stratification guided by EPS results
Discussion
EPS with programmed ventricular stimulation may serve as a useful adjunctive tool for arrhythmic risk stratification in symptomatic athletes with non-ischaemic LV scar and preserved LVEF.
The study population included athletes without conventional high-risk features, a group where risk stratification is particularly challenging
Non-inducibility at EPS was associated with a low event rate (event-free survival of 95.9% at 50 months)
Inducibility identified a subgroup at substantially higher risk of MAE (event-free survival of only 40.6% at 50 months)
The authors conclude that 'EPS may represent a useful adjunctive tool for arrhythmic risk stratification in athletes, particularly in those without conventional high-risk features'
What This Means
This research studied 72 athletes who had non-ischaemic scarring of the left ventricle (heart damage not caused by blocked arteries) but still had a normal pumping function of the heart. All athletes had concerning symptoms such as racing heartbeats, fainting, or dangerous heart rhythm problems during exercise. Researchers performed an electrophysiology study (EPS) — a specialized procedure that tests whether dangerous heart rhythms can be triggered electrically — to see if this test could help identify which athletes were at greatest risk for life-threatening cardiac events.
The study found that about 32% of athletes could have dangerous rhythms triggered during the EPS test ('inducible'), and these athletes had dramatically worse outcomes over a roughly 3.5-year follow-up period. Among inducible athletes, 9 out of 23 experienced a major arrhythmic event, meaning their implanted defibrillators had to deliver a shock to stop a life-threatening heart rhythm. By contrast, only 2 out of 49 non-inducible athletes had such events, and both were successfully resuscitated. Event-free survival at about 4 years was only 40.6% in inducible athletes versus 95.9% in non-inducible athletes — a highly significant difference. Importantly, no one died from an arrhythmia during the study.
This research suggests that EPS testing may be a valuable tool for identifying which athletes with heart scarring and normal heart function are at the highest risk for dangerous rhythm problems, particularly for those who do not have other obvious warning signs. This could help guide decisions about whether to implant a defibrillator device in this challenging-to-assess population. The findings highlight that heart scarring — even without reduced pumping function — can be a serious risk factor in athletes, and that specialized testing may improve individualized risk assessment.
Sciarra L, Ricci F, Cavarretta E, Palamà Z, Borrelli A, Di Roma M, et al.. (2026). Programmed ventricular stimulation for risk stratification in symptomatic athletes with nonischemic left ventricular scar and preserved ejection fraction.. Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. https://doi.org/10.1093/europace/euag160