ECGs in Athletes

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Corrado et al. have published an ESC consensus document on the screening of athletes for competitive sports.[1] Besides a good medical history and examination, a 12 lead ECG is also part of the screening. They have set up special ECG criteria for participants in competitive sports (table 1). If one of the described findings are present on the ECG, the ECG is considered 'positive' and further evaluation is mandatory which can include echocardiography, 24-h ambulatory Holter monitoring, and exercise testing. ECG Features of cardiac diseases detectable at pre-participation screening in young competitive athletes are shown in table 2.

Prevalence of ECG abnormalities in competitive athletes has been studied by Pellicia et al.[2](see table below). ECG abnormalities in their study increased with age and level of exercise. In young amateur athletes they found ECG abnormalities in about 7%, a number that rose to 40% in "adult elite athletes". Especially RBBB and left ventricular hypertrophy were often seen.

A recent study investigated ECG and echocardiographies in male athletes of African / Afro-Caribbean origin and found frequent T wave inversions in leads V1-V4. Significant ST elevation was present in 63.2% and LVH in 23.2%.[3].

Recently fierce debate has been going on about whether an ECG should be part of the screening of apparently healthy young sporters. In Italy this screening is compulsory by law and this country is a strong advocate of the use of an ECG as part of this screening. However, others[4] have stated that costs are too high for the yield (expressed in dollars per prevented sudden cardiac death) and an ECG is not included in the screening protocol of the American Heart Association.[5][6]

Criteria for a positive ECG

Table 1: Criteria for a positive 12-lead ECG
P wave
  • left atrial enlargement: negative portion of the P wave in lead V1 ≥ 0.1 mV in depth and ≥ 0.04 s in duration
  • right atrial enlargement: peaked P wave in leads II and III or V1 ≥ 0.25 mV in amplitude
QRS complex
  • frontal plane axis deviation: right ≥ +120° or left –30° to –90°;
  • increased voltage: amplitude of R or S wave in in a standard lead ≥2 mV, S wave in lead V1 or V2 ≥ 3 mV, or R wave in lead V5 or V6 ≥ 3 mV;
  • abnormal Q waves ≥ 0.04 s in duration or ≥ 25% of the height of the ensuing R wave or QS pattern in two or more leads;
  • right or left bundle branch block with QRS duration ≥ 0.12 s;
  • R or R' wave in lead V1 ≥ 0.5 mV in amplitude and R/S ratio ≥ 1.
ST-segment, T-waves, and QT interval
  • ST-segment depression or T-wave flattening or inversion in two or more leads;
  • prolongation of heart rate corrected QT interval (QTc) > 0.44 s in males and > 0.46 s in females.c
Rhythm and conduction abnormalities
  • premature ventricular beats or more severe ventricular arrhythmias;
  • supraventricular tachycardias, atrial flutter, or atrial fibrillation;
  • short PR interval (< 0.12 s) with or without ‘delta’ wave;
  • sinus bradycardia with resting heart rate ≤ 40 beats/min;a
  • first (PR ≥ 0.21 sb), second or third degree atrioventricular block.
  • aIncreasing less than 100 beats/min during limited exercise test.
  • bNot shortening with hyperventilation or limited exercise test.
  • cA recent study suggests athletes with a QTc > 500ms should be recommended not to participate in competitive sports[7][8]

Cardiac diseases and their ECG features

Table 2: ECG Features of cardiac diseases detectable at pre-participation screening in young competitive athletes
Disease QTc interval P wave PR interval QRS complex ST interval T wave Arrhythmias
HCM Normal (left atrial enlargement) Normal Increased voltages in mid-left precordial leads; abnormal Q waves in inferior and / or lateral leads; (LAD, LBBB); (delta wave) Down-sloping (up-sloping) Inverted in mid-left precordial leads; (giant and negative in the apical variant) (Atrial fibrillation); (PVB); (VT)
Arrhythmogenic right ventricular cardiomyopathy / dysplasia Normal Normal Normal Prolonged > 110 ms in right precordial leads; epsilon wave in right precordial leads; reduced voltages <= 0.5 mV in frontal leads; (RBBB) (Up-sloping in right precordial leads) Inverted in right precordial leads PVB with a LBBB pattern; (VT with a LBBB pattern)
Dilated cardiomyopathy Normal (Left atrial enlargement) (Prolonged >= 0.21s) LBBB Down-sloping (up-sloping) Inverted in inferior and / or lateral leads PVB; (VT)
Long QT syndrome Prolongedc
  • > 440ms in males
  • > 460ms in females
Normal Normal Normal Normal Bifid or biphasic in all leads (PVB); (torsade de pointes)
Brugada Syndrome Normal Prolonged >= 0.21s S1S2S3 pattern; (RBBB/LAD) Up-sloping coved-type in right precordial leads Inverted in right precordial leads (Polymorphic VT); (atrial fibrillation) (sinus tachycardia)
Lenègre disease Normal Normal Prolonged >= 0.21s RBBB; RBBB/LAD; LBBB Normal Secondary changes (2nd or 3rd degree AV block)
Short QT Syndrome Shortened < 300 ms Normal Normal Normal Normal Normal Atrial fibrillation (polymorphic VT)
Pre-excitation syndrome (WPW) Normal Normal Shortened < 0.12s Delta wave Secondary changes Secondary changes Supraventricular tachycardia; (atrial fibrillation)
Coronary artery diseasesa (Prolonged) Normal Normal (Abnormal Q waves)b (Down-or up-sloping) Inverted in >= 2 leads PVB; (VT);
  • Less common or uncommon ECG findings are reported in brackets.
  • QTc: QT interval corrected for heart rate by Bazett’s formula. LBBB: left bundle branch block. RBBB: right bundle branch block. LAD: left axis deviation of –30 degrees or more. PVB: either single or coupled premature ventricular beats. VT: either non-sustained or sustained ventricular tachycardia.
  • aCoronary artery diseases: either premature coronary atherosclerosis or congenital coronary anomalies.
  • bAbnormal Q waves (table 1)
  • cA recent study suggests athletes with a QTc > 500ms should be recommended not to participate in competitive sports[7][8]

Prevalence of ECG abnormalities in athletes

Table 3: Prevalence of ECG abnormalities in an unselected population of 32 652 young individuals undergoing the pre-participation cardiovascular screening
ECG abnormalities Athletes, n (%)
Negative T-waves in precordial/standard leads 751 (2.3)
RBBB 351 (1.0)
Increased R/S wave voltages (suggestive of LVH) 247 (0.8)
Left anterior fascicular block 162 (0.5)
Pre-excitation pattern 42 (0.1)
LBBB 19 (0.1)
Prolonged corrected QT interval 1 (0.003)
Others (incomplete RBBB, prolonged PR interval, early repolarization pattern) 2280 (7.0)
Total 3853 (11.8)
  • RBBB, right bundle branch block; LVH, left ventricular hypertrophy; LBBB, left bundle branch block.[2]

Classification of abnormalities of the athlete’s electrocardiogram

Table 4: Classification of abnormalities of the athlete’s electrocardiogram[9]
Group 1: common and training-related ECG changes Group 2: uncommon and training-unrelated ECG changes
  • Sinus bradycardia
  • First-degree AV block
  • Incomplete RBBB
  • Early repolarization
  • Isolated QRS voltage criteria for left ventricular hypertrophy
  • T-wave inversion
  • ST-segment depression
  • Pathological Q-waves
  • Left atrial enlargement
  • Left-axis deviation/left anterior hemiblock
  • Right-axis deviation/left posterior hemiblock
  • Right ventricular hypertrophy
  • Ventricular pre-excitation
  • Complete LBBB or RBBB
  • Long- or short-QT interval
  • Brugada-like early repolarization

RBBB, right bundle branch block; LBBB, left bundle branch block.



  1. Corrado pmid=15689345
  2. Pellicia pmid=17623682
  3. Maron pmid=17353433
  4. Myerburg pmid=18040041
  5. Chaitman pmid=18040040
  6. Basavarajaiah pmid=17947213
  7. Moss pmid=17967824
  8. Corrado2 pmid=19933514
  9. Papadakis pmid=21613263