Sports cardiology: keeping athletes safe without slowing them down

This article is adapted from the sixth edition of the Foundation’s magazine.

A cardiologist at the Montreal Heart Institute explores the fast-evolving landscape of sports cardiology. 

Dr. François Simard has been specializing in sports cardiology and cardiovascular imaging at the MHI since 2020, working with elite athletes and other physically active individuals. 

He embraces a two-pronged approach: promoting an active lifestyle as a cornerstone of prevention and pinpointing situations where physical effort may reveal underlying vulnerabilities. In this context, performance and health are allies, not adversaries.

Dr. Simard was educated at the Université de Montréal, completing part of his residency and a rotation at the MHI, an environment where he could cultivate his interest in prevention and elite-level sport into a distinct subspecialty. 

“I was immediately drawn to their care philosophy and the chance to develop highly specialized expertise, with strong support from the team,” he said. 

His passion for sports cardiology grew as he encountered various clinical situations first-hand: exertion-related cardiac events, cases of sudden death—rare yet significant—and athletes facing complex diagnoses. The question that kept coming up over and over again: What is the key to practising sport safely? He set out to find answers. 

To be able to delve deeper into this still-emerging subspecialty in Canada, he needed a supportive environment. At the MHI, Drs. Martin Juneau, Peter Guerra, and François-Pierre Mongeon—his mentors—encouraged him to pursue this niche. 

“They said, ‘We believe in what you’re doing. It’s a field that deserves to be developed. Go find the training you need, and we’ll help you make it a reality here.’”

At its core, sports cardiology is about understanding how the heart reacts to exercise. 

“When you’re training at an elite level, your cardiac output can be five to seven times higher than it is at rest,” explained Dr. Simard. 

Exercise changes the structure of the heart: the chambers expand, the walls thicken, the muscles become more efficient. Resting heart rate can drop to as low as 40 beats a minute, sometimes even lower, without it being a medical concern. Dr. Simard recalls an athlete who was worried because his smartwatch had shown a very low heart rate during sleep. “For him, it was actually the sign of a strong, efficient heart—not a problem.” That, in a nutshell, is the essence of sports cardiology: the challenge of distinguishing normal physiological adaptation from true pathology.

At the MHI, Dr. Simard is taking part in one of Canada’s first pilot projects for cardiovascular screening in athletes. He is frequently asked by cardiology colleagues to consult on specialized cases and conducts preventive assessments for sports organizations such as the Institut national du sport du Québec and the Carabins athletic teams at the Université de Montréal. 

His consultations generally focus on two profiles: young athletes whose screening has revealed a suspected anomaly, and veteran athletes aged 35 and over, for whom the primary risk remains coronary disease. 

In the words of an athlete from the Institut national du sport du Québec, “Knowing that we can be assessed here by specialists who understand our reality takes away a lot of our concerns. It makes us feel like we’re being supported rather than held back.” 

Warning signs do exist—chest pain during exertion, fainting, an unexpected drop in performance—but they are not always present. 

“Passing out during physical activity is never something to take lightly. It should be investigated right away,” emphasized Dr. Simard.

Assessing an athlete requires tools tailored to their level of performance. Dr. Simard combines several approaches: stress testing, VO2 max testing—indicating the maximum amount of oxygen the body can use during exercise, and cardiac imaging. 

“Standard tests may not be sufficient for elite athletes,” he said. “Ideally, the assessment should replicate athletic movements as closely as possible. And that’s not always easy.” 

For example, testing a rower’s heart in postures and motions similar to the ones they would adopt on the water provides more accurate readings. 

Imaging plays a central role. Ultrasound technology can assess the heart’s structure and function, while MRIs can, in some cases, detect small cardiac scars or microlesions that would otherwise be impossible to spot. 

Scarred heart tissue, which is sometimes observed in asymptomatic veteran athletes, raises a whole new set of questions: Where did it come from? Will it have an impact on future cardiac risk? What kind of adjustments need to be made in the recommendations made to these athletes? 

These are just some of the avenues being explored in this field—with both caution and curiosity.

Sports cardiology places the athlete at the centre of every decision—and it is perhaps here that the human dimension comes fully into focus. Beyond measuring and diagnosing, it is important to use this information to make the right decisions based on the risks at hand and the individual themselves. 

“Things used to be much more paternalistic,” said Dr. Simard. “Whether an athlete kept going or took a step back was largely their doctor’s decision. More and more, we’re realizing that the athlete must be at the centre of the process. Risks need to be discussed, and the decision must be a shared one.” 

When athletes seek guidance on how to continue training safely, the role of the cardiologist is to provide insight without quashing their momentum. 

The discipline of sports cardiology is still evolving and forging a path at the intersection of science, performance, and responsibility. At the Montreal Heart Institute, it has found fertile ground—a place where leading-edge expertise and a human-first approach can advance hand in hand.

If François’s heart could speak, here’s what it would say:

“Protecting an athlete’s health without undermining their drive is where sports cardiology truly comes into its own. At the MHI, I have the privilege of contributing to the growth of a discipline in which innovation, collaboration, and expertise converge to push the boundaries of both health and performance.”