It is suggested that a 12-lead resting ECG be performed as part of the PCMA. This is because it has been shown that performing an ECG (in addition to taking a history and performing a clinical examination) increases the likelihood of identifying any pre-existing cardiac abnormality. In Italy, where mandatory ECG screening in competitive athletes of all sports has been done for many years, they have reported a reduction in sudden cardiac deaths of about 90%. Abnormalities for which indications may be identified on a screening ECG include hypertrophic cardiomyopathy and arrythmogenic right ventricular dysplasia. For “electrical cardiac diseases” (conduction anomalies) like long QT and WPW syndrome, the resting ECG is the decisive diagnostic tool. It is important to recognise that, for most cardiac diseases, ECG abnormalities may be present.

The interpretation of a screening ECG can be challenging. Normal (“physiological”) cardiac adaptations from athletic training can lead to ECG findings that may be considered pathological when seen in a non-athlete. This is most prominent in endurance athletes but is also present in many football players, as training and competition involve a relevant endurance component. Consequently, a criticism of the use of a ‘routine’ ECG in all athletes, rather than one only performed in individuals with symptoms or a positive family history, is that it leads to a high false-positive rate. This, in turn, may lead to an excessive amount of money being spent on consecutive technical examinations (like echocardiography or even cardiac MRI). ECG changes that are normal in trained athletes are now increasingly recognised, and criteria to help distinguish physiological changes from pathological findings have been continually refined. This culminated in the Seattle Criteria, published in 2013, and the development of an online training course to improve ECG interpretation in athletes. A two-page standardised ECG criteria tool has also been developed. The use of this tool has been shown to improve a clinician’s ability to interpret the ECGs of athletes. It is of particular relevance to acknowledge that healthy black athletes (primarily those of West African origin) display changes suggestive of cardiac disease – particularly those of the T-wave – more often than Caucasians. 19,20

“Standardised criteria for ECG interpretation in athletes: a practical tool“




Click on this link to view a simple tool which you can use to help interpret an athlete’s ECG. This resource has been developed to help clinicans interpret the ECGs of athletes. It has been shown to improve the ability to identify abnormal findings.

The ECG should be performed after at least five minutes of rest. The athlete should lie supine with the 12 leads in the standard positions with the peripheral electrodes positioned on the upper and lower limbs (Einthoven I, II, III and Goldberger aVR, aVL, aVF).

A positive or abnormal ECG mandates further investigation whereas a negative or normal resting ECG is reassuring (high negative predictive value). An echocardiogram and a review from a cardiologist accustomed to treating athletes is generally advisable in the case of an abnormal resting ECG.

Dr Tim Meyer

Sports and Exercise Physician

Click on the following link to read more about the ‘Seattle Criteria’ which was developed to help interpret the ECG’s recorded in athletes.