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International criteria for electrocardiographic interpretation in athletes

Comment by Luis Serratosa, EAPC Sports Cardiology Section

Risk Factors and Prevention

Another step in specificity improvement of athlete’s ECG interpretation criteria

The recently published new international criteria for electrocardiographic interpretation in athletes is a consensus document developed by an international group of sports cardiology experts, according to new research and up to date evidence. The standards are addressed to asymptomatic athletes aged 12-35 years, but also include specific considerations for adolescent athletes aged 12-16 years and for those ≥ 30 years where the prevalence of coronary artery disease increases.

As in the refined criteria (1), ECG findings are categorized into three groups: normal (no further evaluation required), borderline (further evaluation required if 2 or more) and abnormal (further evaluation required to investigate for cardiovascular conditions associated with sudden cardiac death (SCD) in athletes). As a summary, the paper includes a very practical and clear algorithm and two tables with clear definitions and expert opinion-based recommendations for secondary evaluation of specific ECG abnormalities. It is also extensively and nicely illustrated with ECG tracings that complement the text.
Compared to the most recent refined criteria (1), some of the main novelties of these new standards are:

  • Now considered as normal (previously borderline):
    • Isolated QRS voltage criteria for right ventricular hypertrophy
    • ST elevation followed by T wave inversion V1-V4 in black athletes
  • Now considered as borderline (previously abnormal):
    • Complete right bundle branch block

The document will sure serve as a clear guide for appropriate evaluation of ECG abnormalities in athletes, allowing to improve disease detection and limit false-positive results. Since the first criteria were defined by the study group of Sport Cardiology in 2005 (2), each revision of the standards has improved the specificity while maintaining the sensitivity for ECG detectable conditions associated with SCD. According to preliminary data presented during the last Europrevent congress by the group of St. George’s Hospital in London, these new standards may further reduce the rate of false-positives of previous criteria (1-4).
These new International recommendations were co-published in the European Heart Journal and the Journal of the American College of Cardiology. An extended version has also been jointly published in the British Journal of Sports Medicine.


Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology 


1.Comparison of electrocardiographic criteria for the detection of cardiac abnormalities in elite black and white athletes. By Sheikh N, Papadakis M, Ghani S, et al. - Circulation. 2014; 129: 1637-49.
2. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. By Corrado D, Pelliccia A, Bjornstad HH, et al.-Eur Heart J. 2005; 26: 516-24.
3. Recommendations for interpretation of 12-lead electrocardiogram in the athlete. By Corrado D, Pelliccia A, Heidbuchel H, et al. -Eur Heart J. 2010; 31: 243-59.
4. Electrocardiographic interpretation in athletes: the 'Seattle criteria'. By Drezner JA, Ackerman MJ, Anderson J, et al. - Br J Sports Med. 2013; 47: 122-4.

Commented article on:

International criteria (recommendations) for electrocardiographic interpretation in athletes , By Sharma S, Drezner JA, Baggish A, et al. - J Am Coll Cardiol. 2017; 69: 1057-75 & Eur Heart J. 2017.- and by Drezner JA, Sharma S, Baggish A, et al. - Br J Sports Med. 2017.