Indications, protocols, and interpretation of cardiovascular imaging for the evaluation and management of athletes: a clinical consensus statement of the European Association of Preventive Cardiology (EAPC) and the European Association of Cardiovascular Imaging (EACVI) of the ESC: Part 1—Exercise imaging

Exercise imaging, particularly exercise stress echocardiography (ESE), has become a pivotal non-invasive tool for evaluating cardiovascular function in athletes and for distinguishing physiological adaptations from pathological conditions. This Clinical Consensus Statement by the European Association of Preventive Cardiology and the European Association of Cardiovascular Imaging synthesizes current evidence and provides practical guidance on indications, protocols, and interpretation of exercise imaging modalities in both competitive and recreational athletes. The document emphasizes the role of ESE in assessing cardiac reserve, unmasking concealed cardiomyopathies, and stratifying risk in clinical scenarios such as T-wave inversion, exercise-induced repolarization abnormalities, and extreme ventricular remodelling. Special attention is given to imaging protocols tailored to the athletic population, including dynamic assessment of the right and left ventricles, atria, and valvular function during various exercise modalities, highlighting the importance of the functional evaluation in athletes and active individuals. Additionally, the consensus explores the integration of advanced techniques such as cardiopulmonary exercise testing and exercise cardiac magnetic resonance imaging, highlighting their complementary roles in comprehensive cardiovascular evaluation. The statement advocates for individualized testing strategies that consider sport-specific demands, demographic factors such as body size, sex, ethnicity, and the underlying pathology. It also underscores the importance of exercise imaging in guiding sports eligibility and in tailoring exercise prescription for competitive athletes, as well as for patients willing to participate in recreational sports or exercise programs.