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>
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