Roberto Ferrara1, Andrea Serdoz1, Mariangela Peruzzi2 and Elena Cavarretta2,3*
1Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of Rome, piazzale Aldo Moro 5, 00185, Rome, Italy
2Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, corso della Repubblica 79, 04100 Latina, Italy
3Villa Stuart Sport Clinic, FIFA Medical Centre of Excellence, via Trionfale 5952, 00163 Rome, Italy
Received: 21 June, 2017; Accepted: 05 October, 2017; Published: 06 October, 2017
Elena Cavarretta, MD, PhD, Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100 Latina, Italy, E-mail:
Ferrara R, Serdoz A, Peruzzi M, Cavarretta E (2017) How the New International recommendation for Electrocardiographic interpretation in Athletes would change our practice. J Cardiovasc Med Cardiol 4(4): 065-069. 10.17352/2455-2976.000052
© 2017 Ferrara R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Recent evidences in the prevention of sudden cardiac death (SCD) confirmed the importance of pre-participation cardiovascular screening in athletes to early identify, and further disqualify from the competition, all the athletes, if any, affected by life-threatening serious cardiac pathologies that can lead to SCD [1-2]. At present, there is no consensus regarding the optimal strategy for athletes’ pre-participation screening. However, previous data showed that adding the ECG to pre-participation screening evaluation increased the accuracy to detect an underlying cardiovascular disease, in comparison with physical examination and medical history alone [3-4].
In the past, different criteria have been proposed, so a team of experts in sports cardiology aimed to standardize the criteria in ECG interpretation, in order to achieve the maximum sensibility and to improve the specificity, because of the number of false positive is strictly related with the type of criteria and the experience of the operators.
In 2010 the European Society of Cardiology published the recommendations for interpretation of 12-lead electrocardiogram in the athletes with the main objective to differentiate the physiological sport-related adaptive ECG changes observed in athletes from the pathological ECG findings suggestive for cardiovascular disease .
Then in Seattle in 2012, an international team of experts wrote the so-called the “Seattle Criteria”, a revision of ECG interpretation criteria in athletes, in order to increase the specificity without reducing the sensibility of the previous ESC 2010 recommendations .
However, the Seattle criteria were based only on Caucasian athletes and they did not describe some ECG findings that are considered a normal variant in some ethnicity. In particular, Afro-American athletes usually show ECG alterations apparently related to cardiomyopathy [7, 8], but are normal variant. So in 2014 the “Refined Criteria” were published .
In February 2015, in Seattle, a consensus of experts updated the current standard criteria for ECG interpretation in asymptomatic athletes from 12 to 35 years of age. These criteria are based on the latest scientific knowledge and provided physician with a useful tool to accurately recognize the ECG anomalies related to exercise-induced normal finding and exercise-unrelated pathological abnormalities potentially related to SCD in athletes .
The New Recommendations
The electrocardiographic findings are divided in three categories: normal, abnormal and borderline.
Normal ECG findings in athletes
This section describes the normal ECG findings in athletes, including all the ECG aspects related with physiological cardiac adaptation to training, in absence of any other signs suggestive for cardiac pathology.
In example, signs of left or right ventricular hypertrophy are related to the increased dimension of cardiac chamber and correspond to isolated increased QRS voltage criteria without other ECG anomalies. The athlete’s heart is characterized by a homogeneous increase of the four chambers’ dimensions, wall thickness and ventricular mass, while early stages of cardiomyopathy may have an asymmetric distribution between the chambers.
The early repolarization is a frequent pattern in the athletes’ ECG and it is a sign of physiologic heart adaptation to exercise, especially in young athletes, in males and Afro-American ethnicity, compared to sedentary people.
In 2 out of 3 of Afro-American athletes, the early repolarization is associated with T wave inversion in anterior leads (V1-V4) and the physician should consider these anomalies as a benign pattern, like it was described in the Seattle Criteria of 2012.
The authors introduced the concept of “ECG juvenile pattern”, when there is the presence of T wave inversion and biphasic T wave in young athlete who have not reached physical maturity . In particular, in peri-pubertal athletes, the presence of TWI in the anterior leads is not associated with a structural cardiomyopathy  (Figure 1)./p>
- Corrado D, Pelliccia A, Bjørnstad HH, Vanhees L, Biffi A, et al. (2005) 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. Eur Heart J 26: 516-524. Link: https://goo.gl/mujLyP
- Ljungqvist A, Jenoure PJ, Engebretsen L (2009) The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes: March 2009. J Athl Train 44: 538-557. Link: https://goo.gl/UFBWaQ
- Drezner JA, Owens DS, Prutkin JM, Salerno JC, Harmon KG, et al. (2016) Electrocardiographic Screening in National Collegiate Athletic Association Athletes. Am J Cardiol 118: 754-759. Link: https://goo.gl/HsKoSZ
- Drezner JA, Prutkin JM, Harmon KG, O'Kane JW, Pelto HF, et al. (2015) Cardiovascular screening in college athletes. J Am Coll Cardiol 65: 2353: 2355 Link: https://goo.gl/LtXCEU
- Corrado D, Pelliccia A, Heidbuchel H, Sharma S, Link M, et al. (2010) Recommendations for interpretation of 12-lead electrocardiogram in the athlete. Eur Heart J 31: 243-259. Link: https://goo.gl/eqn9iM
- Drezner JA, Ackerman MJ, Anderson J, Ashley E, Asplund CA, et al. (2013) Electrocardiographic interpretation in athletes: the "Seattle criteria". Br J Sports Med 47: 122-124. Link: https://goo.gl/MnEPek
- Riding R, Sheikh N, Adamuz C, Watt V, Farooq A, et al. (2015) Comparison of three current sets of electrocardiographic interprteation criteria for use in screening athletes. Heart 101: 384-390. Link: https://goo.gl/Kh4gDC
- Sheikh N, Papadakis M, Ghani S, Zaidi A, Gati S, et al. (2014) Comparison of electrocardiographic criteria for the detection of cardiac abnormalities in elite black and white athletes. Circulation 129: 1637-1649. Link: https://goo.gl/qSiafG
- Papadakis M, Basavarajaiah S, Rawlins J, Edwards C, Makan J, et al. (2009) Prevalence and significance of T-wave inversions in predominantly Caucasian adolescent athletes. Eur Heart J 30: 1728-1735. Link: https://goo.gl/GEZEeM
- Calò L, Sperandii F, Martino A, Guerra E, Cavarretta E, et al. (2015) Echocardiographic findings in 2261 peri-pubertal athletes with or without inverted T waves at electrocardiogram. Heart 101: 193-200. Link: https://goo.gl/hbsdFD
- Sharma S, Drezner JA, Baggish A, Papadakis M, Wilson MG, et al. (2017) International Recommendations for Electrocardiographic Interpretation in Athletes. J Am Coll Cardiol 69: 1057-1075. Link: https://goo.gl/V4T3GB
- Pelliccia A, Maron BJ, Culasso F, Di Paolo FM, Spataro A, et al. (2000) Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 102: 278 - 284. Link: https://goo.gl/KWuei3
- Xiao HB, Brecker SJ, Gibson DG (1994) Relative effects of left ventricular mass and conduction disturbance on activation in patients with pathological left ventricular hypertrophy. Br Heart J 71: 548-553. Link: https://goo.gl/dDdHoR
- Schwartz PJ, Moss AJ, Vincent GM, Cramptin RS (1993) Diagnostic criteria for the long QT syndrome. An update. Circulation 88: 782-784 Link: https://goo.gl/KKzdMW
- Zorzi A, Leoni L, Di Paolo FM, Rigato I, Migliore F, et al. (2015) Differential diagnosis between early repolarization of athlete's heart and coved-type Brugada electrocardiogram. Am J Cardiol 115: 529-532. Link: https://goo.gl/TKexpR
- Zaidi A, Ghani S, Sheikh N, Gati S, Bastiaenen R, et al. (2013) Clinical significance of electrocardiographic right ventricular hypertrophy in athletes: comparison with arrhythmogenic right ventricular cardiomyopathy and pulmonary hypertension. Eur Heart J 34: 3649-3656. Link: https://goo.gl/4nhbtK
- Gati S, Sheikh N, Ghani S, Zaidi A, Wilson M, et al. (2013) Should axis deviation or atrial enlargement be categorised as abnormal in young athletes? The athlete's electrocardiogram: time for re-appraisal of markers of pathology. Eur Heart J 34: 3641-3648. Link: https://goo.gl/ExP5xd
- Marijon E, Tafflet M, Celermajer DS, Dumas F, Perier MC, et al. (2011) Sports-related sudden death in the general population. Circulation 124: 672-681. Link: https://goo.gl/YddgTG
- Drezner JA, Rao AL, Heistand J, Bloomingdale MK, Harmon KG (2009) Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation 120: 518-525 Link: https://goo.gl/XmcvPs
- de Noronha SV, Sharma S, Papadakis M, Desai S, Whyte G, et al. (2009) Aetiology of sudden cardiac death in athletes in the United Kingdom: a pathological study. Heart 95: 1409-1414 Link: https://goo.gl/FjrcbT
- Drezner JA, Asif IM, Owens DS, Prutkin JM, Salerno JC, et al. (2012) Accuracy of ECG interpretation in competitive athletes: the impact of using standised ECG criteria. Br J Sports Med 46: 335: 340 Link: https://goo.gl/fHJQqt
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