From Screening to Arrhythmia Management: Cedars-Sinai’s Sports Cardiology Program

Interview With Eli Friedman, MD

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EP LAB DIGEST. 2025;26(1):8-9.

Interview by Jodie Elrod

In this interview, we speak with Eli Friedman, MD, director of sports cardiology at the Smidt Heart Institute at Cedars-Sinai, about the launch of the institute’s new Sports Cardiology Program. Dr Friedman discusses how the program provides specialized screening, personalized care, and advanced arrhythmia management—including treatment of atrial fibrillation (AF)—to help athletes and fitness enthusiasts safely achieve their performance goals.

The Smidt Heart Institute’s new Sports Cardiology Program is designed to help athletes and fitness enthusiasts safely participate in sports while managing or preventing cardiovascular issues. Could you share the inspiration behind launching this program at Cedars-Sinai, and how it addresses a gap in care for this unique patient population?

Thank you, I appreciate the opportunity to be here and highlight what we are doing. Sports, athleticism, and exercise continue to increase in prevalence in this country as well as around the world. That is a good thing—exercise is one of the best medicines. We know that people who exercise live longer than those who do not. So, we want people to exercise. For people who make exercise a priority, cardiovascular concerns are inevitable, and within cardiology, athletes represent a unique patient population. They have unique symptoms, needs, and treatments depending on the level of their competition. Cedars-Sinai, a world leader in cardiovascular care, saw an opportunity to build and develop this program. 

We have many high-profile events that come to Los Angeles, and certainly, the city’s climate lends itself well to people being active. It is one thing to exercise for general health benefits, which is great, but it is another when you are pushing your body to be competitive or performing at a professional level. In those cases, cardiovascular concerns can develop, whether related to screening, symptoms, established disease, or return to play. We will get into all those things, but that really opens the door for the field of sports cardiology, which continues to grow. We recognized this opportunity at Cedars-Sinai, and I am grateful and humbled to help direct the program.

Screening athletes for hidden or early heart conditions is a central focus of the program. What tools or strategies do you use to identify arrhythmias in this population, and how does your approach differ when evaluating highly active individuals compared to the general patient population?

Great question. Screening is a big part of what we do, because a lot of people just want to make sure that they are safe before participating in a sport. Maybe they are aware of a family history of heart disease, or someone they know had a heart event so they want to make sure it does not happen to them, or they are mandated to get screening ahead of time before they can participate in their sport. Electrophysiology (EP) is a big part of that. Typical cardiovascular or preparticipation screening before a sport will include patient history, including if there has been any evidence of chest discomfort, shortness of breath, palpitations, or syncope. Those could be precursors to underlying heart disease. We spend a lot of time on family history. We are looking for needles in the haystack that could provide clues for genetic lineage of heart disease, and inherited arrhythmic conditions are a big part of that. We ask patients if they had any relatives who died suddenly, drowned, experienced an unexplained motor vehicle accident, or non-traditional events that we do not typically think of in a family history, but within sports cardiology could be a sign of an arrhythmic episode or inherited heart disease. 

We perform a physical exam as well. While that might not be the most exciting aspect from an EP perspective, it can sometimes detect findings that might otherwise be missed. The major tool that we use is electrocardiography (ECG) screening. There is an ongoing debate in this country about whether ECG screening should be used for all amateur athletes—meaning those in middle school and high school—but we do not have the time or bandwidth to get into that today. We do routinely use ECG screening for collegiate, professional, and Olympic athletes.

We are well aware that certain arrhythmic conditions can reveal themselves on an ECG, with Wolff-Parkinson-White Syndrome being one of the most common, and long QT syndrome is another we often look for as well. If symptoms arise, or if there are abnormalities on the ECG or in the family history, we will take a deeper dive using the diagnostic tools and resources available to us to better understand what is going on. Stress testing, in particular, is something we use frequently in athletes when arrhythmias are a concern. We perform maximal-effort stress testing, and it is not the standard Bruce protocol where you stop at 85% of the predicted heart rate. We want to understand the specific concern and how that intersects with the maximal intensities and efforts of sport. 

We test differently to help provoke arrhythmias such as premature ventricular contractions (PVCs) and premature atrial contractions—these are arrhythmias that we see quite often. AF may not always show up during screening, but PVCs frequently do, and we use imaging to help us better understand those findings. Stress testing is a key tool for assessing the nature of arrhythmias and arrhythmic concerns in our athletes. 

We also use ambulatory monitoring to see what is happening with the athlete in the real world, sending them out with devices that track their heart activity beyond the 4 walls of the clinic. This helps us understand their physiology in real time and how it interacts with the specific demands of their sport.

Athletes often face unique challenges when diagnosed with AF or other rhythm disorders, as treatment decisions can directly impact their ability to train and compete. How do you balance evidence-based therapies—such as catheter ablation or pharmacologic approaches—with an athlete’s desire to remain active at a high level?

The buzzword here is shared decision-making. We spend a great deal of time with these athletes discussing their condition—whether it is AF or another issue—their personal goals, and how we can help them achieve those goals as safely as possible. When an athlete comes into the clinic, we have 2 main objectives: first, to help them continue doing what they love, and second, to ensure they can do it as safely as possible. We work to optimize both as best we can. 

One way to look at it is to think of the sports cardiologist as the quarterback or the point guard of the care team. I am a general noninvasive cardiologist who practices sports cardiology, and I am surrounded by world-class electrophysiologists here at the Smidt Heart Institute. It is very much a team-based, multidisciplinary approach. I may perform certain testing and imaging, then coordinate with my EP colleagues, and together we engage in a shared decision-making discussion with the athlete and their support system to align on goals and tailor individualized therapies.

Oftentimes, the evaluation is very similar to that of the general population. But what makes the difference is really spending time getting to know the athlete—their goals, their sport, and how they train. We make sure to test them in ways that reflect their actual athletic activity; for example, we are not putting a cyclist on a treadmill or a runner on a bike. We tailor stress testing to their specific athletic demands. From there, we take a multidisciplinary approach, recognizing that the person in front of us is an athlete who uses their body differently than someone who exercises casually. Our goal is always to help them continue doing what they love, as safely as possible.

The program emphasizes personalized care plans. Could you walk us through what a tailored evaluation and management strategy looks like for an athlete with a history of AF, or another arrhythmia, who is eager to return to competitive sports?

It begins from the moment the athlete makes that first phone call and schedules an appointment. The first thing we do is take a detailed sports history to understand what the athlete has done in the past, what they are currently doing, and what they hope to do in the future. This helps us personalize our testing and anticipate future risks, stressors, and athletic challenges so we can better understand the condition in front of us. 

From there, we get into the nuts and bolts of the pathology. If it is AF, for example, we determine whether it is paroxysmal or persistent, or if it has previously been classified as permanent. We also evaluate the heart structurally, looking at ejection fraction and whether it is normal or depressed.

We also look for any valvular heart disease or evidence of scar burden, because as we know in the EP field, scar tissue is never a good thing. That can influence how we think about conditions like hypertrophic cardiomyopathy (HCM) and the potential for an implantable cardioverter-defibrillator (ICD). We counsel our athletes that we would never implant an ICD solely for the purpose of allowing continued sports participation, but other factors—such as scar, arrhythmic burden, and PVCs—may affect our decision-making in that regard. 

Ultimately, our goal is to personalize care by aligning the athlete’s performance goals with their underlying pathology, whether that involves an existing arrhythmia or the risk of future ones. We use medications and therapies to maximize safety and support continued participation in exercise, because again, exercise is one of the healthiest things we can do. We just want our athletes to do it safely.

Looking ahead, what role do you see sports cardiology—and specifically EP—playing in broader efforts to prevent sudden cardiac events in athletes? Are there particular innovations in screening, monitoring, or ablation technologies that you think will shape the future of care?

Last year, the Heart Rhythm Society published a consensus statement on the care of arrhythmias in athletes. I think that document raised awareness—among both physicians and patients—of this growing field of sports cardiology. It is a unique way of caring for athletes, and we are developing that same kind of framework and programmatic structure here at Cedars-Sinai, where the electrophysiologist can better understand the athletes in front of them. It is no longer just about performing an ablation or implanting an ICD or pacemaker—it is about working collaboratively with athletes to understand their physiology from an EP perspective and provide tailored, individualized care. I look forward to seeing how this continues to evolve, particularly as leaders in the EP field bring these approaches to more patients. 

In terms of screening, monitoring, and other emerging techniques, I think we will continue to deepen our understanding of athletes as a unique population within EP, especially how the physical demands of athletic performance intersect with arrhythmic pathology. 

Artificial intelligence (AI) is another area I am particularly excited about—I think AI will play a major role in EP going forward. Those of us in this field see a lot of AF, so we need better ways of predicting AF in athletes, and we are learning more about the factors that make athletes more susceptible to AF. In the future, AI may help us identify subtle ECG patterns that look completely normal to the naked eye, helping us predict arrhythmias before they occur. AI could also help us flag those athletes at higher risk for ventricular arrhythmias, such as those with hypertrophic cardiomyopathy, or arrhythmogenic right ventricular cardiomyopathy, and guide earlier decisions about interventions like ICD implantation. 

There is also the potential to improve how we predict sudden cardiac arrest and death—something we all wish we could do more accurately. While we know certain populations are at higher risk, we do not yet fully understand why. As technologies improve, I believe we will be better able to identify those patients who are at higher risk and develop better protocols, treatment plans, and safety nets. 

Monitoring will also continue to expand. Wearables and other devices will allow us to track athletes more closely in the real world. I am truly excited about where the field is heading, especially within EP, which I believe represents the next major frontier. EP has really led the way, inspiring other subspecialties to adopt the sports cardiology model as well, which is great. We need more clinicians in this space, and I am thrilled to see how the field continues to grow.

The transcripts were edited for clarity and length.