International criteria for electrocardiographic interpretation in athletes: Consensus statement

Abstract

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

Accuracy of the ECG for differential diagnosis between hypertrophic cardiomyopathy and athlete’s heart: comparison between the European Society of Cardiology (2010) and International (2017) criteria

“…The International criteria differed from previous recommendations excluding several borderline ECG patterns from those deemed suggestive of pathology with the aim to provide better specificity but maintain the original sensitivity 11. Specifically considering the ECG criteria that may be useful for identification of HCM in Caucasian athletes, the main modifications from the 2010 ESC criteria are the inclusion of isolated LAE and isolated LAD among ECG changes that do not require further investigation based on the study by Gati et al ,28 and the modification by consensus of the definition of ‘pathological’ Q-waves from ‘≥3–4 mm regardless of the Q/R ratio’ to ’depth>1/4 of the height of the ensuing R-wave and/or duration >0.04 s’.…”

“…Subsequently, the criteria have been refined by further documents with the main goal to improve the specificity 9 10. According to the recent (2017) International criteria, a number of ECG changes that were previously considered potentially pathologic (such as left atrial enlargement (LAE) and left axis deviation (LAD) in isolation, T-wave inversion confined to V1–V4 and preceded by J-point elevation in black athletes, Q-waves ≥3–4 mm but <1/4 of the R-wave and <0.04 s in duration) were reclassified as physiologic and not requiring further clinical assessment 11. The aim of this study was to compare the accuracy of the ESC (2010) versus International (2017) criteria for differential diagnosis between HCM and athlete’s heart and to assess the balance between improvement in specificity (reduction of false-positive results) and reduction in sensitivity (ability to identify affected athletes).…”

ECG measurement parameters of athletes are reliable when made with a smartphone based ECG device

“…The International Criteria published in March 2017 is an amalgam of the best evidence to date. 10 It has been endorsed by many governing bodies, including the American Medical Society for Sports Medicine, International Olympic Committee, European Society of Cardiology, and the American College of Cardiology. The International Criteria provides a consensus protocol from which those practicing within the field of cardiologic sports medicine should take direction.…”

Cardiovascular screening practices in US National Governing Bodies and National Paralympic Committees

“…Infrastructure limitations, which include lack of ECG equipment and lack of physicians to interpret the ECG, were cited by nearly half of teams to be a barrier to implementing advanced screening protocols. New international standards for ECG interpretation and recommendations for secondary testing of ECG abnormalities may address other concerns regarding the use of ECG in the screening protocol 4. The results of this study should inform the US NGBs and NPCs in their efforts to ensure that all Olympic-level and Paralympic-level athletes receive appropriate cardiac screening protocols as part of the PHE.…”