IPM Take
Militaries measure almost everything: fitness, vision, hearing, psychological readiness, body composition and physical endurance.
The heart can still be a blind spot.
A new European Association of Preventive Cardiology statement argues that cardiovascular screening should become a more structured part of military recruitment. The evidence is not strong enough to prescribe one universal programme for every country, but the current patchwork is increasingly difficult to defend.
The policy question is not simply whether an ECG can identify hidden disease. It is whether screening can protect service members without producing unfair exclusions, false reassurance or medical decisions shaped more by defence budgets than cardiovascular risk.
Executive Summary
The European Association of Preventive Cardiology, part of the European Society of Cardiology, has published the first comprehensive international framework for cardiac evaluation in the armed forces. The statement was developed by experts from Europe, North America and Australia and published in the European Journal of Preventive Cardiology on 1 July 2026.
Available evidence, much of it from the United States, suggests sudden cardiac death or cardiac arrest may occur more frequently among military recruits than among young athletes. The statement cites rates of approximately 8 to 11 cases per 100,000 recruit-years, compared with roughly 1 to 2 cases per 100,000 athlete-years. However, the true international incidence remains uncertain, and available military data are limited.
The authors say screening may be appropriate for all new military recruits and should be performed for personnel entering high-hazard occupations. A proposed initial assessment includes personal and family history, physical examination and a resting 12-lead ECG. Symptomatic recruits or those with abnormal results may require further evaluation, including echocardiography, exercise testing, ambulatory ECG monitoring, cardiac imaging or genetic assessment where clinically appropriate.
For personnel aged 40 years or older, the statement recommends cardiovascular risk assessment using validated risk calculators in addition to standard screening. This reflects the changing military workforce, where risk increasingly extends beyond inherited disease in young recruits to coronary disease and conventional cardiovascular risk factors in older personnel.
Implementation remains uneven. A related EAPC survey involving 17 military physicians from 14 countries across four continents found that 79% reported screening all recruits, but only 71.4% of countries used ECG-based screening. The small survey cannot provide a complete global picture, but it demonstrates considerable variation in practice.
Why it matters
- Policymakers and defence authorities: Military medical standards need a clearer evidence base, consistent minimum requirements and transparent rules for restricting or approving duty.
- Military health services and clinicians: Screening requires trained professionals, reliable ECG interpretation and access to specialist investigations when abnormalities are found.
- Service members: An abnormal result can affect a career, deployment status and personal identity. Screening programmes need confidentiality, proportionality and fair routes for review or appeal.
- Health systems: Defence services operating with limited budgets may struggle to provide advanced testing after an abnormal screen, creating unequal protection across countries.
- Researchers: Better international data are needed to establish the real incidence, causes and preventability of sudden cardiac death in military populations.
Military recruits are trained to perform under conditions most civilian health systems would consider extreme.
Heat. Cold. Altitude. Sleep deprivation. Psychological pressure. Heavy equipment. High-intensity exertion. Limited access to immediate medical support.
Yet the systems assessing whether a recruit’s heart can tolerate those conditions remain inconsistent.
A new statement from the European Association of Preventive Cardiology argues that military cardiac screening should become more structured, more uniform and more closely adapted to the realities of modern service. It is the first international document to propose a comprehensive framework for cardiovascular evaluation across military branches and occupations.
The starting point is an uncomfortable comparison.
Young athletes have dominated the debate about sudden cardiac death screening for decades. Competitive sports organisations increasingly use pre-participation assessment to identify inherited or structural heart conditions that may become dangerous during intense exercise.
Military recruits often face similar physical demands, combined with operational and environmental pressures that sport does not normally reproduce.
An athletic event can be postponed during dangerous heat. A military operation may not be.
A sporting venue may have defibrillators, emergency teams and a rehearsed response plan. A service member experiencing cardiac arrest during a remote deployment may be hours away from advanced care.
According to the new statement, limited available evidence suggests sudden cardiac death rates of around 8 to 11 cases per 100,000 recruit-years, compared with approximately 1 to 2 cases per 100,000 athlete-years. A large US study cited in the document reported cardiac arrest at 10.8 cases per 100,000 person-years. Another found sudden death rates of 6.7 per 100,000 person-years among male personnel and 1.4 among female personnel, with cardiac disease responsible for 79% of cases.
These figures should be treated cautiously.
The true international rate is unknown. Much of the evidence comes from US military populations, and differences in recruitment, age, sex, training, medical standards and case reporting make direct comparisons difficult.
But uncertainty is not the same as absence of risk.
The EAPC authors propose that cardiac screening may be appropriate for all new recruits, irrespective of their eventual military role. They advise screening for those entering high-hazard occupations, where sudden incapacity could endanger not only the individual but also colleagues and the mission.
The initial pathway is relatively simple: a health questionnaire covering personal and family history, physical examination and resting 12-lead ECG.
The ECG is the controversial part.
It can identify patterns associated with cardiomyopathies, electrical disorders and other conditions linked to sudden cardiac arrest. But it can also generate abnormal or uncertain findings in healthy, physically active people.
A screening programme is therefore only as good as the pathway behind it.
An ECG without trained interpretation can produce false alarms. An abnormal result without access to echocardiography, cardiac MRI, ambulatory monitoring, exercise testing or specialist review can leave recruits trapped between medical uncertainty and career consequences.
The policy failure would be introducing screening as a box-ticking exercise while underfunding everything that follows.
This matters because military medicine is not an ordinary clinical environment.
In civilian care, a patient can often weigh medical advice against personal preferences through shared decision-making. Military fitness decisions also involve commanders, occupational standards, operational risk and the safety of others. The statement acknowledges that the decision-making circle can extend beyond the service member and clinician to include operational command.
That changes the ethical stakes.
Who can access a recruit’s cardiac findings?
How is medical confidentiality protected?
What level of risk justifies exclusion from service or restriction from a particular role?
Can a recruit obtain an independent second opinion?
What happens when a potentially benign ECG variation is interpreted differently by two military systems?
A screening programme designed only around operational protection could become unnecessarily exclusionary. A programme focused only on recruitment numbers could overlook genuine risk.
The answer must be proportionality.
Not every abnormal ECG means that someone is unsafe to serve. Not every cardiac diagnosis carries the same risk in every role. A desk-based cyberwarfare position and a special forces deployment do not impose equivalent physiological demands.
Modern armed forces are no longer divided simply into infantry, artillery and naval service. They include aviation, diving, medicine, logistics, engineering, intelligence, cybersecurity and numerous technical roles. The consequences of sudden incapacity differ dramatically between them.
That diversity supports a layered model.
All recruits could receive a consistent baseline assessment. Additional evaluation could then be targeted according to symptoms, abnormal results, age, cardiovascular risk and occupational hazard.
The related EAPC survey shows how far current practice remains from uniformity. Among respondents from 14 countries, most military services reported some form of pre-participation cardiovascular screening, usually involving a health questionnaire and physical examination. But only 71.4% of participating countries reported ECG-based screening.
That variation may reflect legitimate differences in infrastructure and resources.
It may also mean that a recruit’s chance of having a dangerous cardiac condition detected depends heavily on which uniform they wear.
The authors acknowledge that a fully uniform international model may not be financially realistic. Defence budgets, specialist capacity, conflict pressures and national workforce needs differ. They therefore propose a tiered approach that could allow lower-resource systems to prioritise higher-risk populations while building broader capacity.
This is where the proposal becomes politically difficult.
Cardiac screening competes with many other defence-health priorities. Governments may question whether testing thousands of asymptomatic recruits is justified when sudden cardiac death remains rare and the diagnostic yield is uncertain.
That is a legitimate question.
Screening should not be adopted because it sounds responsible. It should be evaluated for the number of serious conditions detected, false-positive rates, cost, psychological consequences, impact on recruitment and evidence that it prevents deaths.
The statement itself concedes that the yield of screening in military cohorts remains incompletely defined.
But doing nothing is also a policy choice.
Militaries already invest heavily in training people for physically and strategically demanding roles. Discovering a serious cardiac condition only after a collapse, deployment emergency or years of specialised training is costly in human, operational and financial terms.
The strongest case for screening is therefore not that every cardiac tragedy can be prevented.
It is that defence systems should stop treating hidden cardiovascular risk as unpredictable when structured detection is increasingly possible.
Soldiers are expected to be ready for extreme conditions.
Their health systems should be ready too.
