In April, the cycling community was shocked by the sudden death of 23-year-old Belgian Michael Goolaerts at Paris-Roubaix after suffering cardiac arrest. Tragic as it was, it wasn’t an isolated incident — in 2016, 22-year-old Belgian rider Daan Myngheer died in a hospital two days after suffering a heart attack at Criterium International. Here, Dr. Kevin Sprouse, Head of Medicine for EF Education First-Drapac powered by Cannondale, shares his views on sports cardiology and the complex nature of heart screening for professional cyclists.

The subspecialty of sports cardiology is still somewhat in its infancy. The body of knowledge is growing rapidly and consensus expert opinion can change fairly quickly, if it is reached at all.

It’s been more than a month since the dust settled on Paris-Roubaix, regarded by many as the sport’s most important one day race — a race put into stark perspective by the death of a rider. Michael Goolaerts, a 23-year-old Belgian cyclist, suffered cardiac arrest during the race and later passed away at the hospital in Lille. While tragedies like this are uncommon in sports, they happen frequently enough that they have become increasingly familiar.

As a sports medicine specialist and team doctor in cycling’s WorldTour, I find these stories both heartbreaking and unsettling. In the days after Paris-Roubaix, I read articles and heard podcasts discussing cardiac testing and risk for riders. I found that some information was good, some was incomplete, and many of these publications left more questions than answers.

First and foremost, I should make it clear that I have no specific insight into Michael Goolaerts’ case. What I can share is information on the current science regarding sudden cardiac death (SCD) in athletes and how our team screens riders for potential heart problems.

At the Pro Continental and WorldTour level, all riders are required to undergo annual cardiac testing. This consists of an electrocardiogram (or “ECG”), cardiac questionnaire, and physical exam for every rider, every year. Additionally, they must undergo either a Stress ECG or a Resting Echocardiogram each year, alternating one year to the next. This is a very comprehensive screening protocol, and some would argue that it goes above and beyond what the evidence suggests is useful.

The efficacy of screening tests is a tricky topic. Of course, we want to detect all potential problems, but that must be balanced against the incidence of “false positives.” We do not want the inaccuracy of tests to lead to the disqualification of a healthy individual, so a good screen must pick up present conditions and appropriately determine when those conditions are not present. That sounds simple, but it can be a difficult hurdle.

Using the UCI testing protocol, I have seen riders devastated when told they have a disqualifying cardiac condition, only to undergo further testing which shows they do not. Likewise, I’ve worked with riders who have had years of normal tests, only to develop a cardiac issue in the middle of a season. It is an imperfect science, at best.

The subspecialty of sports cardiology is still somewhat in its infancy. The body of knowledge is growing rapidly and consensus expert opinion can change fairly quickly, if it is reached at all.

There are two categories of cardiac conditions in athletes which seem to get continuous media coverage. The first is sudden cardiac death in young, competitive athletes. The second is heart problems in older, lifelong athletes, which can present with either death or dysrhythmia (irregular heart rates). These are very different conditions. Young athletes tend to be afflicted by congenital or structural heart disease. Older athletes (over the age of 35) are more likely to suffer from acquired diseases such as blocked arteries or scarring affecting the electrical pathways. Because of this, the screening for each group can be quite different.

As we learn more about SCD in young athletes, we are able to detect the underlying conditions more accurately on screening. Tragically though, one of the most common presenting symptoms of these cardiac conditions in athletes is still sudden death. In other words, death is often the first sign that there is a problem. Again, I know nothing about the medical details of Michael Goolaert’s condition, but it is entirely conceivable, if not likely, that he had years of normal cardiac testing.

I have read and heard people subtly question whether Goolaert’s doctors adequately investigated and/or addressed his risk. I don’t know, but I prefer to give them the benefit of the doubt. This is a very difficult topic for Sports Medicine doctors. Even when issues are found on testing, they are rarely black and white.

Cardiac screening is complex and imprecise. Without a doubt, team doctors all want their athletes to be able to do what they love — to compete — and do it safely. At the end of the day, screening is not perfect. In cycling, we do more than is done in many sports. There will unfortunately always be tragedies that occur, but hopefully there are many more that are prevented that you will never hear about.