The American College of Cardiology and the American Heart Association issued new cardiovascular guidance for clinicians who care for tactical athletes — a category that includes military, emergency response, and public safety personnel whose health can directly affect public safety. The recommendations, published in JACC and Circulation, explain how to evaluate and manage tactical athletes with existing cardiovascular disease or those at risk for developing it. Authors estimate about 4 million Americans fill these roles.
The guidance aims to fill a gap distinct from competitive-sports cardiology by accounting for the ways duty-related demands and occupational exposures change clinical risk and operational decisions.
Tactical athletes are professionals whose performance serves community safety rather than competition. Examples cited in the guidance include EMTs, firefighters, police officers, Marine pilots, Navy SEALs, Army engineers, and astronauts.
The concept of tactical athletes was first recognized in the early 2000s, and the new guidance builds on experience from sports-cardiology frameworks developed since the 1980s and 1990s to create recommendations tailored to service-oriented roles.
The guidance emphasizes several occupational stressors that alter cardiovascular risk in tactical athletes. Key factors include abrupt transitions from rest to maximal exertion without warm-up, exposure to extreme temperature, deep water, high altitude, heavy protective equipment, and acute emotional stress such as facing imminent danger.
Benjamin Levine, vice chair of the guideline-writing group, described the scenario: often there is no opportunity to warm up — an emergency call can demand immediate, high-level performance. The guidance highlights that such sudden, intense exertion combined with threat of harm can increase the risk of cardiovascular events. For firefighters, event rates rise as soon as an alarm sounds, and the period between alarm and arrival at a scene is a recognized peak time for cardiac events.
Specific occupational exposures may add unique risk in subgroups. For astronauts, researchers hypothesize that increased radiation exposure during spaceflight may accelerate atherosclerosis. For active-duty service members and firefighters, prevalence of traditional cardiovascular risk factors compounds occupational strain.
The guidance notes that many tactical-athlete populations have higher rates of established cardiovascular risk factors such as hypertension, high cholesterol, obesity, type 2 diabetes, and smoking. In a reported dataset, 18% of active-duty service members had at least one of five major risk factors (high cholesterol, high blood pressure, hypertension, diabetes or prediabetes, or obesity) and 24% were active smokers.
Firefighters with prior diagnoses of cardiovascular disease, hypertension, or smoking were more likely to suffer fatal cardiovascular events, according to the guidance. Although overall rates of sudden cardiac arrest or death are low, the risk increases during recruit training and in acute duty situations.
Tim Churchill, of the Cardiovascular Performance Program at Mass General Brigham, noted that the varied and sometimes extreme conditions of tactical work can exacerbate underlying problems even if the jobs themselves do not necessarily increase baseline cardiovascular disease risk.
Cardiovascular fitness and capacity often change over the course of a tactical athlete’s career. Someone who met screening standards as a recruit may develop reduced capacity with age, aligning them with older “masters” athletes whose risk rises with age.
Brian Becerra, director of sports cardiology at UC Irvine, emphasized that a lack of capacity for one role does not preclude service in another capacity. The guidance supports context-based reassignment or job adjustment — for example, moving a person from field duties to planning or administrative tactical roles — rather than an absolute disqualification from service when cardiovascular changes occur.
The guidance therefore recommends clinicians consider the specific physical demands of an individual’s role, the most extreme tasks they may be called to perform, and whether alternative duties can preserve both the individual’s career and public safety.
A notable difference from recent competitive-sports guidance is how decisions about continued duty are framed. Competitive-athlete guidance has emphasized shared decision-making between clinician and athlete; by contrast, the new tactical-athlete guidance recognizes that outcomes of clinical decisions can affect others’ lives and so gives greater weight to organizational stakeholders.
The tactical athlete retains basic rights to medical care and should receive best clinical practices for assessment and treatment. However, because incapacitation on duty may endanger teammates or the public, command structures or other organizational leaders may have a larger role in final determinations about job assignment or continued operational duties.
Benjamin Levine explained that while clinicians should apply standard care, the consequences of a tactical athlete’s incapacitation justify involvement by those responsible for operational safety.
The guidance is intended to help cardiologists and other clinicians better understand the unique physiological and situational demands faced by tactical athletes and to apply tailored evaluation and management strategies. Practitioners are urged to assess both traditional cardiovascular risk factors and job-specific exposures, consider career-stage changes, and discuss practical job adjustments when appropriate.
Experts quoted in the article — including Levine and Lili Barouch of Johns Hopkins Medicine — welcomed the focused framework and emphasized the importance of recognizing the emotional as well as physical stressors in tactical roles. The guidance aims to balance the tactical athlete’s individual health rights with the broader safety responsibilities intrinsic to their professions and to provide clinicians with a clearer roadmap for role-specific cardiovascular care.
The STAT report notes that sports cardiologists have welcomed the guidance as addressing an unmet need for highly elite professionals who serve public safety. Specific operational recommendations, algorithms, and detailed clinical protocols were reported as being published in the JACC and Circulation guidance documents referenced in the article.