81% of football associations screen players' hearts. Few do it the same way

Pre-participation cardiac screening in football is often described as though it were a settled global standard. A survey published this month in the British Journal of Sports Medicine, covering every FIFA member association, shows how much variation sits underneath that description [s1].

What was surveyed

FIFA sent a 21-point questionnaire to all 211 member associations between February and July 2024, and 165 responded — a 78% response rate [s1]. The questions covered whether cardiac screening is recommended or mandated for elite players, what the protocol contains, and at what age and interval youth players are screened.

A 78% response rate is high for a survey of national federations, but the 46 non-responders are not random, and associations with no screening programme at all may be likelier to have skipped it. The figures below describe the associations that answered.

The headline numbers

Cardiac screening was recommended or mandated by 81% of responding associations — 134 of 165 [s1].

That aggregate hides a wide confederation spread. Within the South American confederation, all 10 responding associations recommend or mandate screening — 100% [s1]. Within the Oceania confederation, 3 of 9 do, or 33% [s1].

Among the 134 associations that do screen, the core protocol is fairly consistent. A majority use a protocol including at least a medical history, a physical examination and a 12-lead ECG: 123 of 134 (92%) for adult male players, 119 (89%) for adult female players, 112 (84%) for youth male players and 108 (81%) for youth female players [s1].

Echocardiography is where the protocols diverge. It is included for 91 of 134 associations (68%) for adult male players and 84 (63%) for adult female players, but only 59 (44%) for youth male and 59 (44%) for youth female players [s1]. Adding an echocardiogram roughly doubles the cost and the specialist time a screening episode requires, which is the most obvious explanation for the adult–youth gap, though the survey does not test it.

The youth timing problem

The survey's least tidy finding concerns when youth screening begins. The median age at initial cardiac screening was 14 years (IQR 4), with a range from 6 to 17 [s1]. The interval between repeat screenings was likewise described as highly variable [s1].

That eleven-year spread matters clinically. Several of the cardiac conditions associated with sudden cardiac arrest in athletes express themselves on an ECG only after puberty, so a player screened at 6 and not again until adulthood may pass through the period of highest yield unmonitored. Conversely, screening very young players generates false positives and follow-up testing with its own costs. The survey documents the variation without adjudicating which end of it is right.

The authors' conclusion is that routine cardiac screening is widely, but not uniformly, applied, and that standardised global recommendations for both adult and youth football are needed [s1].

What a single national programme looks like

A study published in July gives a concrete picture from inside one of the confederations with the lowest screening uptake. New Zealand Football screens players for FIFA tournaments with a personal and family history, physical examination, resting 12-lead ECG and transthoracic echocardiogram — the fuller protocol, including the echo that most associations reserve for adults [s2].

An audit in March 2024 reviewed the programme's records since 2012 and included 147 footballers, 60% female, mean age 19.2 ± 3.7 years [s2]. Fewer than five players received a diagnosis of a condition associated with sudden cardiac arrest or death; the study reports rare results as "<5" to protect anonymity [s2]. No player retired for cardiac reasons, and there were no incidents of sudden cardiac arrest or death during the audit period [s2].

Of the ECGs, 4.8% were abnormal — but no player with an abnormal ECG was subsequently found to have underlying structural heart disease on echocardiography [s2]. The authors report that the ECG and echocardiographic findings in this cohort resembled those of other football populations [s2].

That combination — a small number of true findings, a 4.8% abnormal-ECG rate that did not translate into structural disease, and no events — is roughly what screening programmes of this size are expected to produce. It is also why the cost-effectiveness argument over echocardiography is not easily settled from any single national dataset.

Limits

The FIFA survey describes policy, not practice. An association reporting that screening is recommended is not evidence that every eligible player is screened, or that abnormal findings are followed up. The New Zealand audit covers 147 players across roughly a decade — informative about that programme, too small to estimate the rate of any rare condition.

Neither study measures whether screening prevents deaths. That question requires event data across much larger populations, and it remains the unresolved core of the debate over ECG-inclusive screening.

What to watch

Whether FIFA converts the survey into a standardised recommendation, and if so whether it specifies a youth screening age and interval — the two parameters the survey found most variable [s1].

Sources

• Global cardiac screening practices among youth and adult football players: the FIFA cardiac screening survey — British Journal of Sports Medicine, 2025-09-08
• Results of a cardiac screening program in elite football players in New Zealand — Science and Medicine in Football, 2025-07-18