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12-lead ECG plays a central role in the cardiovascular evaluation of athletes and highly active patients. Based on the ability of the ECG to detect underlying structural and electrical cardiac disease, the ECG is the most widely used diagnostic test during pre-participation screening of asymptomatic athletes and individualised evaluation of symptomatic athletic patients. ECG interpretation in this population, however, may present a formidable challenge. Cardiovascular adaptations to routine high-intensity exercise coupled with factors including age, gender, and ethnicity result in ECG patterns that are uncommon among more sedentary people and, in come cases, similar to those associated with the key cardiac diseases responsible for sudden cardiac death.
In an attempt to provide a conceptual and clinically applicable framework for ECG use in athletes, interpretation criteria have been developed. A working group from the European Society of Cardiology (ESC) presented the first such criteria in 2005.1 While valuable as a starting point, the 2005 ESC criteria failed to differentiate benign ECG patterns associated with exercise training from those associated with occult disease and, as such, their application in clinical settings led to unacceptably high rates of false positive testing. Since that time, further work from the ESC writing group,2 paralleled by independent efforts from others,3 have led to revised criteria. Contemporary athlete ECG criteria rely on the principle that ECG patterns among athletes can be divided into ‘common and training-related ECG changes' (ie, benign adaptive findings) and ‘uncommon and training-unrelated ECG changes’, with this latter category touted as being highly suggestive of underlying disease. Recent …