Association Between Neighborhood Opportunity With Exercise-Related Cardiac Symptoms and ECG Abnormalities in US Youth Athletes

BACKGROUND: Sudden cardiac arrest disproportionately affects youths from lower socioeconomic neighborhoods, yet the mechanisms of this disparity in youth athletes remain unclear. METHODS: We retrospectively analyzed the HeartBytes National Youth Cardiac Registry (Simon’s Heart, a US nonprofit for sudden cardiac death prevention), in which youth athletes aged <17 years completed standardized cardiovascular symptom questionnaires before attending community-based preparticipation screening events, including physical exam and 12-lead ECG, across the United States between April 2015 and May 2024. Neighborhood opportunity was determined by linking residential zip code to census tract level child opportunity index 3.0 scores (range 1–100; higher values indicate greater opportunity), a composite spanning educational, health, environmental, and social and economic domains, with athletes grouped into national quintiles. Multivariable logistic regression examined associations between child opportunity index quintile and exercise-related cardiac symptoms and ECG abnormalities, adjusting for demographics, anthropometrics, hemodynamics, and comorbidities. RESULTS: Among 7843 youth athletes (median age, 14 years; 38.9% female; 83.0% White), distribution across child opportunity index quintiles was 7.4% very low, 4.3% low, 6.7% moderate, 16.7% high, and 65.0% very high. Compared with the very high quintile, athletes in the very low quintile had higher prevalence of exercise-related chest pain (9.1% versus 3.7%), exercise-related fatigue (11.4% versus 7.0%), and abnormal ECGs (10.0% versus 5.1%; all P <0.001). After multivariable adjustment, participants in the very high child opportunity index quintile had lower odds of exercise-related chest pain (adjusted odds ratio, 0.45 [95% CI, 0.32–0.63]), exercise-related fatigue (adjusted odds ratio, 0.65 [95% CI, 0.47–0.87]), and abnormal ECGs (adjusted odds ratio, 0.58 [95% CI, 0.42–0.82]) relative to the very low quintile. CONCLUSIONS: Youth athletes from lower-opportunity neighborhoods were underrepresented in preparticipation screening and demonstrated higher prevalence and adjusted odds of exercise-related cardiac symptoms and ECG abnormalities. Prospective longitudinal studies are needed to determine clinical significance and inform equitable screening strategies.