Evaluation and Risk Stratification of Ventricular Premature Complexes in Athletes: Practical Considerations for Differentiating Benign from Malignant Arrhythmias

Ventricular premature complexes (VPCs) are common in athletes, but distinguishing benign VPCs from malignant arrhythmias remains a clinical challenge. This review summarizes current evidence on VPC evaluation and risk stratification in athletes, emphasizing electrocardiographic (ECG) features, burden, morphology, coupling interval, and exercise response. While VPC prevalence in athletes mirrors the general population, high-risk features–such as non-fascicular, non-outflow tract morphologies (e.g., superior axis or wide QRS), short coupling intervals (<300 ms), and VPC exacerbation during exercise - correlate with underlying structural heart disease (e.g.,arrhythmogenic cardiomyopathy, idiopathic left ventricular scar) and adverse outcomes. Guideline-directed assessment recommends comprehensive evaluation for athletes with high VPC burden (>10%), complex arrhythmias, or abnormal imaging. Key findings include: (1) VPC-induced cardiomyopathy risk rises with burden >5–10%, though low-burden VPCs may still indicate arrhythmogenic substrates; (2) uncommon morphologies (e.g., non-fascicular, non-outflow tract morphologies) predict cardiac pathology; and (3) exercise-induced VPCs, warrant further cardiac imaging to screen for arrhythmogenic substrate. A structured algorithm integrating clinical history, ECG, stress testing, and advanced cardiac imaging optimizes risk stratification and sports participation guidance. This review underscores the need for individualized management to mitigate sudden cardiac death risk while avoiding unnecessary sports restriction in athletes with benign VPCs.