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Using modern criteria, ECG is the most effective strategy for screening of CVD in athletes

Comment by Luis Serratosa, EACPR Sports Cardiology Section

The effectiveness of screening history, physical exam, and ECG to detect potentially lethal cardiac disorders in athletes: A systematic review/meta-analysis.

K.G. Harmon, M Zigman, JA Drezner.

Journal of Electrocardiology 48 (2015) 329–338

doi: 10.1016/j.jelectrocard.2015.02.001.


Preparticipation screening for the early detection of potentially life threatening cardiac diseases is worldwide recommended by a growing number of sports and scientific organisations. According to the 30 years Italian experience, adding a 12-lead resting electrocardiogram (ECG) to the athlete’s preparticipation examination (PPE) may significantly decrease the incidence of sudden cardiac death (SCD). There is anyway a quite passionate ongoing debate regarding the best screening strategies and even if there should be any screening at all. The USA approach has traditionally been against the inclusion of the ECG, but this review/meta-analysis article from KG Harmon et al., comes from one of the USA groups supporting the resting ECG as part of the PPE.

Database entries were searched from January 1996 to November of 2014, for articles examining the efficacy of screening with history and physical examination (PE) based on the American Heart Association (AHA) or similar recommendations and ECG interpreted using modern standards. From a total of 787 articles yielded by the literature review, 15 met the selection criteria and could be finally included for full review. One of the strengths of the review is that it combines data on the screening of 47,137 athletes and active adolescents (5 to 39 years; 66% males and 34% females), from diverse countries and ethnicity (Algeria, France, Germany, Greece, Netherlands, Qatar, Spain, United Kingdom, and United States), with a measure of the quality of the studies and meta-analysis of pooled data.

The main concern of the AHA and those opposing the inclusion of the ECG as part of the PPE, is that this strategy may increase the number of athletes falsely diagnosed with disease.

However, this review shows that the ECG is actually:

  • 5 times more sensitive than history (94 vs 20%)
  • 10 times more sensitive than physical exam (9%)
  • has a lower false positive rate (6%) than either history (8%) or physical exam (10%)

even when considering that 9 of the 15 studies used older ECG criteria such as the 2005 or 2010 ESC criteria. This heterogeneity of ECG criteria used for interpretation represents one of the limitations of the study. The newer Seattle and Refined Criteria (1) have further decreased the false positive rate while retaining the sensitivity to detect pathologic conditions. The most impressive reduction in the false-positive ECG rate with these new criteria has been shown in black athletes, who exhibit more profound ECG changes compared to other ethnic groups and represent a large proportion of athletes in certain countries and sports. Future analysis of studies using the same new ECG criteria will likely decrease statistical heterogeneity and therefore yield more reliable results.

The review also showed a total of 160 (0.3%) potentially lethal cardiovascular conditions, which is consistent with other studies. Electrical disease (Wolff-Parkinson-White, Long QT Syndrome) was the most common pathology identified, suggesting that it might be a more common cause of death than cardiomyopathies. But related to these findings, we should also mention that not all athletes were screened with definitive studies (echocardiogram, cardiac magnetic resonance imaging, and genetic testing) and therefore pathology may have been missed.

Based on the results of the review, I would agree with the author’s conclusions supporting the 12-lead ECG using the latest refined interpretation criteria, agreed from international consensus, as best practice in screening for cardiovascular disease in athletes, while the use of history and physical alone as a screening tool should be re-evaluated.


(1) Sheikh N, Papadakis M, Ghan S et al. Comparison of Electrocardiographic Criteria for the Detection of Cardiac Abnormalities in Elite Black and White Athletes. Circulation. 2014; 129:1637-1649.

Author: Luis Serratosa

EACPR Sports Cardiology Section

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