Performance of the 2010 European Society of Cardiology Criteria for ECG Interpretation in Athletes

Study Questions:

Using transthoracic echocardiography as the standard for cardiac structural abnormalities, how successful were the 2010 European Society of Cardiology (ESC) revised criteria for ECG interpretation among college athletes?


University athletes (n = 508) underwent routine medical history, physical examination, and ECG before athletic participation. Transthoracic echocardiography was also performed on each participant to detect or exclude cardiac findings with relevance to sport participation. Screening test statistics were calculated to determine the performance of the 2010 ESC criteria, and the performance of the 2010 criteria was compared with the 2005 criteria.


Application of the 2010 ESC criteria, compared with the 2005 criteria, reduced the number of participants with abnormal ECG findings from 83 of 508 (16.3%) to 49 of 508 (9.6%). The reduction in the number of abnormal ECGs was driven by the reclassification of participants with isolated QRS voltage criteria for left ventricular hypertrophy from abnormal to normal. Of the 49 participants with abnormal ECGs, 14 of 49 (29%) had a single ECG abnormality and 35 of 49 (71%) had two or more abnormalities. The use of the 2010 criteria was associated with improved specificity (reduction in the false-positive rate) and preserved sensitivity when compared with the 2005 criteria.


The authors concluded that application of the 2010 ESC criteria for ECG interpretation in the athlete improves the accuracy of an ECG-inclusive preparticipation screening strategy by reducing the rate of false-positive ECGs.


Using echocardiography as a standard for the detection of structural heart disease, the revised 2010 ESC guidelines for ECG interpretation in athletes are more specific than are the previous guidelines published in 2005. Improved test specificity is important to avoid unnecessarily excluding athletes without structural heart disease. However, the clinically relevant endpoint remains the detection of healthy young athletes at risk of sudden cardiac death; because this study was not powered to assess that outcome, it remains a matter of active debate as to whether ECG screening is appropriate, in part because it carries the risk of excluding from athletic participation athletes who are not at risk.

Clinical Topics: Noninvasive Imaging, Sports and Exercise Cardiology, Echocardiography/Ultrasound, Sports and Exercise and Imaging

Keywords: Athletes, Cardiovascular Diseases, Hypertrophy, Physical Examination, Echocardiography

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