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]

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.
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.

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 Prolonged
  • > 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)



  1. Corrado pmid=15689345
  2. Pellicia pmid=17623682