Comparison of Electrocardiographic Criteria for the Detection of Cardiac Abnormalities in Elite Black and White Athletes

Study Questions:

What are the relative accuracies of various criteria for electrocardiogram (ECG) interpretation in black athletes and white athletes?


Between 2000 and 2012, 1,208 black athletes were evaluated with history, physical examination, 12-lead ECG, and further investigations as appropriate. ECGs were retrospectively analyzed according to the European Society of Cardiology (ESC) recommendations, Seattle criteria, and proposed refined criteria, which exclude several specific ECG patterns when present in isolation. All three criteria also were applied to 4,297 white athletes and 103 young athletes with hypertrophic cardiomyopathy.


The ESC recommendations raised suspicion of a cardiac abnormality in 40.4% of black athletes and 16.2% of white athletes. The Seattle criteria reduced abnormal ECGs to 18.4% in black athletes and 7.1% in white athletes. The refined criteria further reduced abnormal ECGs to 11.5% in black athletes and 5.3% in white athletes. All three criteria identified 98.1% of athletes with hypertrophic cardiomyopathy. Compared with ESC recommendations, the refined criteria improved specificity from 40.3% to 84.2% in black athletes and from 73.8% to 94.1% in white athletes without compromising the sensitivity of the ECG in detecting pathology.


Refinement of current ECG screening criteria has the potential to significantly reduce the burden of false-positive ECGs in athletes, particularly black athletes.


There is an ongoing debate about whether amateur athletes should be universally screened with an ECG in order to detect potentially life-threatening underlying cardiac disease. An important negative of universal ECG screening is lack of test specificity, necessitating additional testing (and possibly risking exclusion from athletic participation) in the absence of significant disease. ESC criteria for ECG screening in athletes were derived predominantly from white athletes, and do not account for the effect of Afro-Caribbean ethnicity (which is associated with a higher prevalence of ECG abnormalities without underlying cardiac disease). This study suggests that the newly published Seattle criteria (Drezner JA, et al. Br J Sports Med 2013;47:122-4) and other revised criteria can improve test specificity of screening ECGs in athletes without compromising test sensitivity, with an important incremental improvement in test specificity among black athletes.

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