Perspective:

This editorial accompanies two papers in the same journal, reviewing what is known and proposing changes to the European Society of Cardiology (ESC) consensus document on recommendations for the interpretation of 12-lead electrocardiography (ECG) in the athlete. The following are points to remember:

1. Preparticipation ECG screening is intended to exclude from participation athletes with underlying cardiac disease and associated increased risk of sudden death.

2. Athletic conditioning is associated with adaptive neuroanatomic (increased vagal tone/withdrawal of sympathetic activity) and structural changes (increased left ventricular [LV] and right ventricular [RV] mass [due to increase in both cavity dimension and wall thickness]) and that in turn are expressed as ECG changes (sinus bradycardia, 1° and 2° atrioventricular [AV] block, early repolarization, increased QRS voltage, incomplete right bundle branch block [RBBB]). In determining which athletes have underlying cardiac pathology, it is of importance to recognize ECG findings that are abnormal in the general population yet are normal in a trained athlete.

3. Establishing criteria for a normal athlete ECG should take into account the relative sensitivities and specificities of various ECG findings for the presence of underlying cardiac pathology. High sensitivity is desired in order to identify the greatest possible number of athletes at risk of sudden cardiac death, whereas high specificity is desired in order to minimize additional cardiac testing and maintain reasonable cost-effectiveness of screening.

4. Existing ESC guidelines divide ECG findings in athletes into ‘Group 1’ (common/training-related) and ‘Group 2’ (uncommon/training unrelated), and that additional diagnostic testing is warranted only for athletes with ‘Group 2’ findings.

5. Existing Group 1 findings are sinus bradycardia, 1° AV block, notched QRS in V1 or incomplete RBBB, early repolarization, and isolated QRS voltage criteria for LV hypertrophy. Existing Group 2 findings are T-wave inversion, ST-segment depression, pathologic Q waves, complete RBBB or left bundle branch block, nonvoltage criteria for RV hypertrophy, ventricular pre-excitation, long or short QT interval, and Brugada-like early repolarization.

6. Based on data published since the ESC recommendations in 2010, the authors propose the following changes:

a) Addition to Group 1 findings of isolated QRS voltage criteria for RV hypertrophy.

b) Terming all of the existing Group 2 ECG findings as ‘Major.’

c) Creation of a ‘Minor’ Group 2 subset of ECG findings consisting of left-axis deviation, right-axis deviation, left atrial enlargement, and right atrial enlargement.

7. The management of patients with the new ‘minor’ Group 2 ECG findings is open to debate. The authors propose that including them as abnormal and therefore recommending additional testing would marginally (3-4%) decrease screening ECG specificity and increase (2-4%) sensitivity for detection of underlying cardiac pathology.

8. Although Europe and the International Olympic Committee endorse preparticipation screening of athletes with routine ECG, this is not endorsed by US amateur athletic groups.