Sudden cardiac death in athletes, particularly children, is a terrible occurrence that generally represents an undetected underlying cardiac abnormality that doesn’t present itself until too late. Across the world, various health policies have been implemented to try to mitigate the risk inherent to athletic participation and to optimize the preparticipation clearance process — an admirable and certainly noble goal. The loss of any child is tragic, even more so while actively participating in sports which encourage physical fitness and teach young people important life lessons such as discipline, teamwork, and determination.
As a response to this phenomenon, in 2025 Florida’s state legislature passed the “Second Chance Act,” named after a 2024 incident of sudden cardiac death of a Florida teenager. This bill was subsequently signed into law, requiring high school athletes in the state to have at least one screening ECG prior to participation in sports starting with the 2026-2027 school year. This makes Florida the first state in the nation to require ECGs for high school sports participation.
Per the text of the law, an ECG within the last two years is acceptable for clearance. Additionally, the law will allow for religious and medical exemptions. While Florida law allows MDs, DOs, NPs, and chiropractors to complete preparticipation medical examinations, only MDs and DOs will be allowed to give a patient a medical exemption to an ECG. If an ECG is abnormal, athletes will be prohibited from participating in sports until obtaining written medical clearance. Lastly, the law also requires school districts to “pursue public and private partnerships to provide low-cost electrocardiograms.” Students will be exempt from the requirement if their school district is unable to coordinate a partnership that provides ECGs at $50 or less.
While the law is an admirable step toward saving lives, it is not without controversy.
First, the incidence of sudden cardiac events is low, with fewer than 100 per year in the U.S. State-specific data are more difficult to come by, but an artificial intelligence search of media reports suggests fewer than 10 deaths in the state of Florida over the last decade among high school athletes.
Second, the evidence in favor of screening ECGs has received pushback. The most cited study on the topic comes from the Veneto region of Italy, where a decrease in the incidence of sudden cardiac deaths was observed after implementation of the screening requirement in 1982. The reported decrease was substantial, from 3.6 deaths per 100,000 person-years prior to screening to 0.4 per 100,000 person-years.
However, though this study showed a benefit to screening, it was not methodologically exact, nor was it directly applicable to the U.S. context. Namely, the pre-screening period (only three years) for the Italian study was significantly shorter than the post-screening period of over 20 years. In a low-incidence event such as this, year-to-year variation in occurrences could substantially alter the statistics. Further, the most common cause of sudden cardiac death in athletes in the study was due to arrhythmogenic right ventricular cardiomyopathy, whereas the most common cause in the U.S. is hypertrophic cardiomyopathy. Finally, although ECGs were beneficial in this particular study, another study comparing the same region of Italy (where ECGs were a required component of screening) with Minnesota (where screening did not include ECG) showed no difference in sudden death in athletes.
Another country that adopted the screening requirement is Israel, which in 1997 implemented mandatory ECG and exercise stress testing for young athletes before playing sports. However, despite the additional screening beyond 12-lead ECG to include exercise stress testing, there was no observed difference in sudden cardiac deaths after the implementation of this requirement. Interestingly, the Israeli researchers found that if they restricted the pre-screening period to the two years before enactment of the required pre-participation screening, they too would have found a statistically significant decrease in mortality that did not hold true when analyzing the entire study period. This suggests that year-to-year variation in the incidence of low frequency events could cause significantly different reported outcomes based on the study period evaluated.
Given the above, there is considerable debate within the medical community regarding the effectiveness of mandatory ECGs for screening among athletes, particularly in the U.S. where the incidences of various cardiac abnormalities differ considerably from the best reported evidence for screening from a specific region in Italy. While the European Society of Cardiology recommends mandatory screening ECGs, the medical consensus in the U.S. has generally been against universal preparticipation ECGs. Neither the American Heart Association (AHA) nor the American College of Cardiology recommend mandatory preparticipation screening with ECG, with the AHA as recently as March 2025 reiterating that both ECGs and echocardiograms are “best used as follow-up if an initial screening raises suspicions about the presence of a cardiovascular disease.” In their policy position, they additionally stated “any expansion of screening programs should be made in response to new science.”
Beyond the medical piece of the conversation, there are enormous logistical and socioeconomic constraints to consider. Studies have shown that false positive findings on screening ECGs in athletes are anywhere between 1.3-6.8%, a significant portion albeit smaller than the 10% false negative rate that shows ECGs aren’t perfect at detecting hypertrophic cardiomyopathy. Based on these false positive rates, a worst-case scenario could yield over 5,000 student-athletes across the state of Florida who will be prohibited from participation during the upcoming school year until obtaining further medical clearance, despite not having a true abnormality. Obviously false negatives that miss an important cardiac abnormality are harmful, but it is easy to forget false positives cause a different kind of harm as well. These students will incur missed playing time, potential social stigma from peers, potential mental health effects, and lack of physical activity in a time when roughly 20% of children are obese, according to the CDC.
ECG readings vary by interpreter and this will certainly affect both the true and false positive and negative rates. The bulk of this work will be placed on primary care physicians, not pediatric cardiologists or electrophysiologists. Certain physicians will be less comfortable interpreting pediatric ECGs due to lack of experience and lack of volume historically in their practices, and many pediatrician offices do not even have ECG machines.
According to the Florida High School Athletic Association, roughly 308,000 students participated in athletics during the 2024-2025 school year. With the start of the requirement beginning with the 2026-2027 school year for students participating for the first time in high school athletics, there will be nearly $4 million yearly in healthcare costs to account for new freshmen ECGs. This does not take into account future office visits, echocardiograms, or any other workup as a result of a positive screen. While one could certainly never put a price on the life of a child, these are significant costs that will have to be absorbed by families and/or their health insurance.
Highlighting access issues, in the capital city of Florida, there is exactly one pediatric cardiologist. Many student-athletes across the state will face a significant access barrier when referred for abnormal ECG findings. While larger metropolitan areas will be better served, there will likely be longer wait times for referrals and/or significant travel required to see a specialist for further workup. This will also affect patients with other medical conditions requiring pediatric cardiology care, as time-to-appointment will increase as the volume of referrals increase.
I cannot think of anything more honorable than striving to save the lives of children. That being said, the medical evidence and consensus (or lack thereof) on mandatory preparticipation screening ECGs in athletes is highly varied at best even within the medical community, with reasonable physicians on both sides of the issue having different opinions. We can all agree that we want our patients to be healthy and children to be safe while participating in sports — but the best way to do that in this scenario is not clear, and I’m not convinced mandatory universal screening ECGs regardless of risk stratification are the answer. Florida will likely be a case study for mandatory screening ECGs in high school athletes in the U.S., and regardless of the outcome it could chart the way forward for the rest of the nation.
Do you support mandatory screening ECGs in high school athletes? Why or why not? Share your reasoning in the comments.
Dr. Del Carter is a family medicine resident physician in Tallahassee, FL. He enjoys traveling, watching Florida Gators sports, working on cars and motorcycles, and spending time with friends and family. He can be found on Instagram and X at @DelCarterMD. Dr. Carter was a 2024–2025 Doximity Op-Med Fellow, and continues as a 2025–2026 Doximity Op-Med Fellow.
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