Standardizing Cardiovascular Screening for Military Personnel

Interview With Mark Abela, MD

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EP LAB DIGEST. 2026;26(9).

Interview by Isabel Vega 

The first international consensus statement on cardiovascular evaluation in military personnel establishes a standardized framework for screening recruits and service members. In this interview, Mark Abela, MD, discusses the recommendations and their potential to improve cardiovascular screening in military personnel and other physically demanding occupations.

This is the first international consensus statement focused on cardiovascular evaluation in military personnel. What makes military populations unique, and why was standardized screening guidance needed?
Mark Abela, MD: A substantial body of evidence supports cardiovascular screening in athletes, and those recommendations have been refined over many years. In military populations, however, the evidence remains limited despite their distinct occupational demands.

In athletes, we often rely on shared decision-making. When a cardiovascular condition is identified, we counsel the athlete about the risks, and medical support is generally available during training or competition if an event occurs. In military settings, however, service members may operate under intense physical and psychological stress in extreme environments where rapid access to medical care is limited.

Our goal is to identify individuals at increased cardiovascular risk as early as possible, ideally before recruitment. The statement also supports surveillance for those with borderline findings and consideration of periodic screening because cardiovascular risk may change over time.

The statement recommends a standardized screening approach that includes a health questionnaire, physical examination, and resting electrocardiogram (ECG) for new recruits. What evidence supports this approach, and how could it improve early detection of cardiovascular disease?
Mark Abela, MD: Most of the recommendations are informed by evidence from cardiovascular screening in athletes. We believed a similar framework was appropriate for military personnel because they face similar cardiovascular demands during strenuous physical activity.

As a consensus document, the statement is intended to provide practical guidance and harmonize screening practices. We cannot say definitively yet that this approach will reduce cardiovascular event rates. However, standardization is an essential first step. It will allow institutions to collect more consistent data, better define the population at risk, and strengthen collaboration. Over time, these efforts should help determine the effect of screening on cardiovascular outcomes.

The recommendations place particular emphasis on personnel in high-hazard occupations and those aged 40 years or older. Why are these groups especially important to evaluate?
Mark Abela, MD: Age is one of the most important considerations in cardiovascular screening. In younger individuals, the primary goal is to identify inherited or genetic conditions that may increase the risk of sudden cardiac events. In this group, the resting ECG is particularly valuable because it has good sensitivity for detecting many of these disorders. The health history and physical examination provide complementary information.

In older individuals, especially those with cardiovascular risk factors, the focus shifts toward atherosclerotic coronary artery disease. A resting ECG is less sensitive for detecting underlying coronary disease before an event. For this reason, we emphasize formal cardiovascular risk assessment using validated risk scores and, when appropriate, additional evaluation with ischemia testing or coronary anatomy assessment.

The consensus emphasizes a multidisciplinary approach when cardiovascular abnormalities are identified. How can collaboration across specialties improve clinical decision-making and care for military personnel?
Mark Abela, MD: Recruits are often young and otherwise healthy, so establishing an accurate baseline is essential. Screening findings may affect whether an individual is cleared for military service, and those decisions must account for both the individual's health and the institution's operational needs.

Multidisciplinary expertise helps balance the risks of missed disease and overdiagnosis. Not every military organization has access to a cardiologist with expertise in this area, but involving clinicians who understand sports cardiology, inherited cardiovascular disease, electrophysiology, and occupational requirements can help ensure that individuals receive appropriate testing, counseling, and management.

Looking ahead, how do you hope these recommendations will improve cardiovascular care for military personnel, and could they help shape screening strategies for other physically demanding professions?
Mark Abela, MD: The primary goal is to harmonize cardiovascular screening. The statement provides a tiered approach, beginning with core recommendations that can be implemented broadly and extending to additional evaluation for institutions with greater resources.

Before developing the statement, we conducted a European Association of Preventive Cardiology survey to assess current practices across countries. We found substantial variation. Not all countries routinely screen military personnel, and those that do often use different protocols. Some use more intensive screening than we propose.

A standardized approach should improve consistency, generate higher-quality data, and provide a common framework for military screening. Military screening is also influenced by operational and geopolitical realities, which made achieving international consensus challenging. The same principles may also inform screening in other physically demanding occupations.

Is there anything else you would like to add for our readers?
Mark Abela, MD: An important question is what happens after screening. Identifying cardiovascular abnormalities is only useful if there is a clear pathway for further evaluation and decision-making.

In athletes, shared decision-making is well established. The military setting is different because medical support may be limited during operations. Decisions may therefore require a more command-directed approach that considers the individual's preferences, operational requirements, and institutional responsibilities.

For example, I would be hesitant to deploy someone with a potentially high-risk arrhythmic phenotype to a hostile environment where timely medical care may not be available. Future guidance should address fitness for military service with clearer criteria for entry, continued service, deployment, and, when necessary, disqualification. Those recommendations will likely differ from existing guidance for athletes.
 

The transcripts were edited for clarity and length.