A new consensus document on electrocardiographic interpretation in athletes: does it help to prevent sudden cardiac death in athletes?
Neth Heart J
A new consensus document on electrocardiographic interpretation in athletes: does it help to prevent sudden cardiac death in athletes?
N. M. Panhuyzen-Goedkoop 0 1
H. T. Jørstad 0 1
J. L. R. M. Smeets 0 1
0 Radboud University Medical Centre , Radboudumc, Nijmegen , The Netherlands
1 Academical Medical Centre Amsterdam , Amsterdam , The Netherlands
Sudden cardiac arrest or death (SCA/SCD) in athletes has a low event rate. Pre-participation or eligibility screening is a widely accepted method of primary prevention of SCA/SCD in athletes. Most European countries and international sports governing bodies perform ECG-inclusive screening. However, implementation of a resting 12-lead ECG in pre-participation or eligibility cardiac screening is still a topic of debate. Recently, the 'International recommendations for electrocardiographic interpretation in athletes' was published in three leading international medical journals. These international ECG criteria are based on studies with detailed information on resting 12-lead ECG of Caucasian and Afro-Caribbean athletes or on consensus in case evidence was lacking. Normal, borderline and abnormal ECG findings in young athletes (age 12-35 years) are clearly described and illustrated to assist the screening physician in interpreting ECGs of athletes correctly. In this 'point of view paper' we will discuss whether these new ECG criteria actually help prevent SCA/SCD in athletes.
Athlete; ECG; Sudden cardiac death; Pre-participation screening; Prevention
Sudden cardiac arrest and/or death (SCA/SCD) in athletes
is a very tragic event that attracts a lot of media attention.
The key question conventionally raised after such an event
resulting from lethal ventricular arrhythmia, i. e. ventricular
tachycardia/fibrillation (VT/VF), is: could this have been
prevented? SCD in competitive athletes aged 35 years and
younger (young athletes) is rare (0.6–2.85/100,000
annually). The incidence is considerably lower than in the
overall population (3–10.7/100,000 annually) and significantly
lower than the incidence of VT/VF in Europe (84.0/100,000
]. Most inherited and congenital
cardiovascular diseases (CVD) in athletes at risk of VT/VF can
be identified during life [
]. To date, primary
prevention with pre-participation or eligibility cardiac screening is
a widely accepted method to reduce SCA/SCD in athletes
]. If pre-participation or eligibility cardiac screening
fails to identify athletes at risk, secondary prevention with
bystander resuscitation, including defibrillation with
automatic external defibrillator (AED), is essential to save an
athlete’s life . However, an AED is no adequate
replacement for pre-participation or eligibility cardiac screening
]. How we need to screen athletes for conditions
predisposing to VT/VF optimally is a topic of debate.
In this manuscript we discuss the ‘International
recommendations for electrocardiographic interpretation in
athletes’, questioning if these new ECG criteria help
preventing SCA/SCD in athletes [
Pre-participation cardiac screening
The purpose of pre-participation or eligibility cardiac
screening in athletes is identifying CVD at risk of VT/VF
and reducing SCA/SCD by disease management [
Pre-participation or eligibility cardiac screening consists of
personal and family history taking and physical
1, 8–10, 15
]. Pre-participation or eligibility cardiac
screening performed by most European countries and
international sports governing bodies include a 12-lead resting
1, 8, 16
]. In the Netherlands, pre-participation or
eligibility cardiac screening is performed by sports
physicians according to the ‘Lausanne protocol’ [
Borderline ECG finding
Left atrial enlargement
Right atrial enlargement
Left axis deviation
Right axis deviation
ESC European Society of Cardiology, FPR false positive rate
AV atrioventricular, ECG electrocardiogram, RBBB right bundle branch block, LVH left ventricular hypertrophy, RVH right ventricular
participation or eligibility cardiac screening results raise
suspicion of a CVD at risk of VT/VF additional cardiac
evaluation is recommended before clearing the athlete [
]. To adequately perform pre-participation or eligibility
cardiac screening, the screening physician needs training
and skills in physiology, ECG interpretation, CVD at risk
of VT/VF, and CVD management in athletes [
In 2010, the European Society of Cardiology (ESC) for
the first time classified athlete ECGs in training-related and
training-unrelated or pathologic ECG findings [
Training-related ECG findings induced by vagotonia and
volume and/or pressure overload of the cardiac cavities are
an expression of athlete’s physiologic cardiac adaptation
or remodelling [
16, 19, 20
]. The ESC 2010 criteria were
principally based on a large Italian registry in almost
exclusive Caucasian young athletes [
]. Left atrial
enlargement, cardiac axis deviation and criteria of right
ventricular hypertrophy (RVH) were classified as pathologic ECG
]. However, the typical ECG changes of left
ventricular hypertrophy (LVH) and ST-T changes in
AfroCaribbean ethnicity were not mentioned and therefore
regarded as abnormal. This resulted in a high false positive
rate of ECG-inclusive screening (FPR 8.8–26.5%) [
The Seattle 2013 criteria were based on ECG data in both
Caucasian and Afro-Caribbean athletes [
ST-segment elevation combined with T-wave inversion in
leads V1-4 in Afro-Caribbean athletes’ was classified as
training-related . However, left atrial enlargement,
cardiac axis deviation and RVH were still classified as
The so-called ‘borderline ECG findings’ were introduced
by Sheikh et al. because the issue of the resemblance of
an athlete’s ECG and pathology had not been solved [
The Refined criteria regarded left atrial and right atrial
enlargement, cardiac axis deviation, RVH and T-wave
inversion in leads V1-4 in Afro-Caribbean athletes
normal findings if considered in isolation, but abnormal if
two or more patterns were present [
]. Using the
Refined criteria, a lower FPR was observed in a cohort of
predominantly young ( 35 years) male Caucasian (FPR
6.1%) and Afro-Caribbean (FPR 15.8%) athletes
(Table 1; [
]). A lower FPR using the Refined criteria was
also observed in an Arabic study in young male athletes
(FPR Caucasians 2.5%, Afro-Caribbeans 3.1%) and in
adolescent soccer players (FPR Caucasians 2.1%,
AfroCaribbeans 9.2%) (Table 1; [
]). Although ECG
screening demonstrated different FPR results in
non-comparable cohort studies the Refined criteria were a major step
forward in evidence-based ECG interpretation in athletes.
Research, in particular that of Sharma et al. (London,
United Kingdom), conducted to describe in detail ECGs of
athletes of different ethnicity, gender and intensity of sports
participation has been of great value for the consensus of
the international ECG criteria [
12–14, 19, 20, 26, 27
third document, endorsed by several international
(European Society of Cardiology, American Heart Association,
American College of Cardiology) and national cardiac
societies, sports medicine societies and sports governing bodies,
is an updated practical consensus for the screening
physician to interpret and recognise physiologic and pathologic
ECG findings in athletes [
Normal, borderline and abnormal ECG findings in athletes
The international consensus ECG criteria describe and
illustrate each separate ECG finding at rest in young athletes
]. The ECG findings are classified as normal,
borderline and abnormal.
Normal or training-related ECG findings are induced by
long-term sports participation on a regular basis for at least
four hours per week [
]. As is mentioned above, these
ECG findings at rest reflect increased vagotonia and cardiac
remodelling in athletes (Table 2; Fig. 1). Such ECG
findings warrant no further cardiac evaluation and the athlete is
eligible to play.
Borderline ECG findings are left atrial and right atrial
enlargement, electrical axis deviation and complete right
bundle branch block (RBBB). When found in isolation in
asymptomatic athletes with a negative family history of
inherited CVD or SCA/SCD these findings are classified as
normal and need no further cardiac evaluation (Table 2;
]). However, when two or more borderline findings
are present and/or the athlete is symptomatic and/or has
a positive family history, these borderline ECG changes are
classified as abnormal and additional cardiac evaluation is
warranted before clearing the athlete [
Abnormal ECG findings are pathologic changes until
proven otherwise. These abnormal findings reflect CVD
at risk of VT/VF (i. e. inherited or congenital CVD,
myocarditis, coronary disease) recommending additional
cardiac evaluation before clearing the athlete to participate
in sports (Figs. 2 and 3). The international ECG criteria
clearly describe and illustrate the details of abnormal ECG
findings suspicious of CVD at risk of VT/VF [
Does this international consensus document help to prevent VT/VF in athletes?
The consensus-based recommendations for ECG
interpretation in athletes assist the screening physician in identifying
athletes at risk of VT/VF. However, false positive rate (FPR)
and false negative rate (FNR) of pre-participation or
eligibility cardiac screening remain a problem. On the one hand,
false positive test results wrongly identify athletes at risk of
VT/VF, lead to unnecessary additional cardiac evaluation at
high costs and result in uncertainty about the athlete’s career
]. On the other hand, wrong eligibility
decision-making in false negative test results can put athletes at risk of
]. To reduce FPR results, the screening
physician must be well-trained in interpreting ECGs of athletes
and is recommended to use the most recent ECG criteria
describing the lowest FPR [
18, 20–22, 27, 30
]. Future studies
need to demonstrate that the international ECG criteria will
result in a lower or equal FPR as compared with the Refined
ECG criteria. However, there are several limitations
inherent to ECG-inclusive pre-participation or eligibility cardiac
screening, including the interpretation of an ECG at rest
alone. Sometimes the ECG changes are very subtle and
difficult to recognise. In myocarditis and cardiac
concussion in blunt chest trauma these subtle ST-T changes are
not always initially present. Furthermore, certain
congenital and inherited CVDs (i. e. coronary anomaly, premature
coronary syndrome, catecholaminergic polymorphic
ventricular tachycardia) cannot be identified at a resting-ECG
alone. Besides, abnormal ECG findings of a CVD at low
risk of potential lethal cardiac events (i. e. atrial fibrillation,
AV nodal re-entry tachycardia) are a confounder of the
purpose of pre-participation or eligibility cardiac screening to
identify athletes at risk [
1, 4, 5, 10
]. Finally, ECG findings
in other ethnicities, such as Hispanic, Asian and mixed
ethnicity, and in athletes over 35 years of age and children are
not included in this consensus document.
ECG-inclusive pre-participation cardiac screening to
prevent SCA/SCD in athletes is implemented by most
European countries and international sports governing bodies.
The international ECG criteria, endorsed by international
cardiac and sports medical societies and sports governing
bodies, pose an updated and clear guide in interpreting
ECGs of athletes to appropriately identify abnormal ECG
findings at rest suspicious of CVD at risk of VT/VF. The
screening physician must be trained in interpreting ECGs
of athletes following the most recent ECG criteria to avoid
wrong decision-making. Further studies are needed to
determine if these updated international ECG criteria help to
prevent SCA/SCD in athletes (12–35 years of age).
Conflict of interest N.M. Panhuyzen-Goedkoop, H.T. Jørstad and
J.L.R.M. Smeets declare that they have no competing interests.
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