Myocardial infarction in athletes: Epidemiology, pathophysiological mechanisms, diagnostic challenges, and preventive strategies

Myocardial infarction (MI) among athletes is an uncommon but clinically significant event that has attracted growing attention because of its potential to cause sudden cardiac death (SCD) and long-term morbidity in an otherwise healthy population. This review synthesizes current literature on the epidemiology, pathophysiology, diagnostic evaluation, and preventive strategies for MI in athletes across age groups. In athletes younger than approximately 35 years, MI is rare and is more often attributable to non-atherosclerotic mechanisms—congenital coronary artery anomalies, spontaneous coronary artery dissection, coronary artery spasm, myocardial bridging, an oxygen supply–demand mismatch related to hypertrophic cardiomyopathy, or performance-enhancing substance use—than to classic atherosclerotic coronary artery disease. In masters athletes, generally older than 35 years, atherosclerotic plaque rupture or erosion, frequently triggered by the acute hemodynamic stress of intense exertion, becomes the predominant mechanism. Preparticipation cardiovascular screening, incorporating structured history-taking, physical examination, and standardized electrocardiographic interpretation criteria, together with the widespread availability of automated external defibrillators and bystander cardiopulmonary resuscitation training, constitutes the principal preventive strategy, although its optimal design and cost-effectiveness remain debated. Following an acute event, individualized, shared-decision-making approaches to return-to-play balance the cardiovascular and psychological benefits of continued exercise against residual arrhythmic and ischemic risk. Continued research into advanced imaging biomarkers, genetic testing, and risk-stratification tools is needed to refine clinical care for this distinctive population.