An editorial recently published in the Journal of the American College of Cardiology by an authoritative group of international experts has drawn attention to the little-known and often underestimated problem of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in athletes, and the fundamental need for clinical research in this area, which has been almost “forgotten” until now[1].
“Even a single death from pulmonary embolism is too many when the majority are preventable” –state the authors, referring to the collegiate athletes analyzed in a large U.S. case series (2), a particular type of patient because, “despite the rarity of deaths from pulmonary embolism, in most cases a triggering factor was involved, unlike what happens in the general population, where about half of the cases are unprovoked”[1].
The National Collegiate Athletic Association case series
The American case series referred to is that of the National Collegiate Athletic Association of the University of Washington. This work constitutes the first population-level report on sudden death related to pulmonary embolism in collegiate athletes [2]. The data collected cover two decades, from 2002 to 2022, and highlight eleven deaths due to pulmonary embolism (0.12 per 100,000 athlete-years) in the 18–22 age group. This number is largely underestimated, according to the authors, because only “sudden deaths” attributed to pulmonary embolism were considered, whereas deaths occurring days or weeks after an initial diagnosis of venous thromboembolism may not have been detected.”
Of notable interest is the finding that all “sudden deaths” caused by pulmonary embolism occurred at rest. These events might therefore escape exercise-focused emergency preparedness strategies. It should be noted, however, that more than a third of the cases had been preceded by dyspnea (respiratory fatigue, Ed.). This is an important finding that confirms what emerged from recent research promoted by the Arianna Anticoagulazione Foundation, the PEDIS study, according to which the recent onset of severe respiratory fatigue during mild exertion, especially in young subjects, can be a revealing (and often underestimated) symptom of pulmonary embolism.
Furthermore, most cases occurred in the presence of transient triggers, including recent surgery, trauma, acute illness, or the use of oral contraceptives.
The authors therefore emphasize the need to carefully assess the risk of thromboembolism in athletes, in the perioperative or post-injury period, and to consider the opportunity to perform thromboprophylaxis when indicated.
“In young athletes, particularly in the weeks following surgery, trauma, or illness, respiratory fatigue should prompt consideration of venous thromboembolism in the differential diagnosis,” write the experts—”Similarly, limb swelling not clearly related to local trauma should be carefully evaluated by the sports medical team, and caution should be exercised regarding vigorous massage of the area before ruling out deep vein thrombosis to minimize the risk of clot embolization, should one exist“[1].
What are the consequences for athletes?
Although, fortunately, sudden death due to pulmonary embolism was a rare event in the group of young athletes analyzed, it must be considered that even non-fatal pulmonary embolism and deep vein thrombosis can cause long-term health problems, interrupt careers, and create complex management dilemmas for athletes and their medical teams.
Decisions on anticoagulant therapy, which may seem simple in other types of patients, become incredibly complex in professional athletes, in whom the conflicting priorities of effective thrombosis treatment and the risk of bleeding during return to competitive activity must be carefully balanced. Direct oral anticoagulants (DOACs), with their short half-life and predictable anticoagulant activity, offer the possibility of “personalized” management of therapy, but there is currently a lack of clinical studies that allow for the definition and validation of management procedures[3].
What can already be done?
Practical measures that sports organizations and physicians can adopt immediately include the assessment of potential risk factors for venous thromboembolism (particularly family history and personal factors such as oral contraceptives in female athletes), improving the recognition of symptoms of venous thromboembolism by both athletes and staff, including the development of clear protocols for the evaluation of unexplained dyspnea or syncope in the weeks following surgery or injury, and the establishment of routine perioperative risk assessments[1].
“Awareness and education of athletes regarding the impact of venous thromboembolism both in the general population and among sportspeople can be valuable so that the public and athletes themselves understand when an urgent evaluation is necessary.
Furthermore, athletes, professional organizations, and the medical community should collaborate to prioritize surveillance, prevention, and research on venous thromboembolism,” write the international experts, concluding that “Only through coordinated efforts can we hope to reduce the impact of venous thromboembolism and prevent future tragedies”[1].
A stimulus for research
Unfortunately, the lack of complete information in the analyzed study regarding the various transient risk factors to which athletes may have been exposed (such as long travel, use of doping agents, or hormonal therapies), together with the limited number of events, precluded more in-depth analysis. The authors therefore emphasize the need for multicenter registries that track both fatal and non-fatal venous thromboembolism in athletes, with standardized data collection on transient exposures, to define the true incidence, identify modifiable risk factors, and inform evidence-based prevention strategies. “Such registries should be linked to data on clinical outcomes and return to competitive activity, so that management algorithms can be tested and refined.” –they emphasize[1].
A call to which the Arianna Anticoagulazione Foundation has already responded by organizing an observational study, in collaboration with the Federation of Centers for the Diagnosis of Thrombosis and Surveillance of Antithrombotic Therapies (F.C.S.A.), the objective of which is to collect the decade-long experience of Italian specialist centers that have managed sportspeople and athletes suffering from venous or arterial thromboembolism on antithrombotic therapy and to provide useful information for patient management, particularly regarding the safe resumption of sports activity.
The clinical study will be presented at the next Arianna Foundation Conference, Anticoagulazione, to be held in Bologna on July 2, 2026, during which Prof. Elena Campello will speak about the management of venous thromboembolism in athletes.
For registration, please consult the following link: 10th Arianna Anticoagulazione Foundation and Anticoagulazione.it Conference – Bologna, July 2, 2026 – anticoagulazione.it
Read also: Anticoagulant therapies and sport: a new FCSA consensus
Edited by Sophie Testa and Stefania Cavazza
Bibliography
- Bikdeli B, Middeldorp S, Wasfy JH, Spyropoulos AC, Jimenez D. Fatal Pulmonary Embolism in Professional Athletes: A Window Into a Broader VTE Problem. J Am Coll Cardiol. Published online May 13, 2026. doi:10.1016/j.jacc.2026.03.166
- Weller SL, Petek BJ, Churchill TW, et al. Sudden death from pulmonary embolism in National Collegiate Athletic Association athletes: insights from a 20-year registry. J Am Coll Cardiol. https://doi.org/10.1016/j.jacc.2026.03.076
- Nazha B, Pandya B, Spyropoulos AC, Kessler CM. Treatment of venous thromboembolism in elite athletes: a suggested approach to individualized anticoagulation. Semin Thromb Hemost. 2018;44:813–822. https://doi.org/10.1055/s-0038-1673690
