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Original research article
Diagnostic accuracy and Bayesian analysis of new international ECG recommendations in paediatric athletes
  1. Gavin McClean1,2,
  2. Nathan R Riding1,
  3. Guido Pieles3,
  4. Victoria Watt4,
  5. Carmen Adamuz4,
  6. Sanjay Sharma5,
  7. Keith P George2,
  8. David Oxborough2,
  9. Mathew G Wilson1,2
  1. 1Athlete Health and Performance Research Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  2. 2Research Institute for Sport and Exercise Science, Liverpool John Moores University, Liverpool, UK
  3. 3National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Centre, Congenital Heart Unit, Bristol Royal Hospital for Children and Bristol Heart Institute, Bristol, UK
  4. 4Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
  5. 5Department of Cardiovascular Sciences, St Georges University of London, London, UK
  1. Correspondence to Professor Mathew G Wilson, Athlete Health and Performance Research Centre, ASPETAR Qatar Orthopaedic and Sports Medicine Hospital, Doha 29222, Qatar; mathew.wilson{at}


Objective Historically, electrocardiographic (ECG) interpretation criteria for athletes were only applicable to adults. New international recommendations now account for athletes ≤16 years, but their clinical appropriateness is unknown. We sought to establish the diagnostic accuracy of new international ECG recommendations against the Seattle criteria and 2010 European Society of Cardiology (ESC) recommendations in paediatric athletes using receiver operator curve analysis. Clinical context was calculated using Bayesian analysis.

Methods 876 Arab and 428 black male paediatric athletes (11–18 years) were evaluated by medical questionnaire, physical examination, ECG and echocardiographic assessment. ECGs were retrospectively analysed according to the three criteria.

Results Thirteen (1.0%) athletes were diagnosed with cardiac pathology that may predispose to sudden cardiac arrest/death (SCA/D) (8 (0.9%) Arab and (5 (1.2%) black)). Diagnostic accuracy was poor (0.68, 95% CI 0.54 to 0.82) for 2010 ESC recommendations, fair (0.70, 95% CI 0.54 to 0.85) for Seattle criteria and fair (0.77, 95% CI 0.61 to 0.93) for international recommendations. False-positive rates were 41.0% for 2010 ESC recommendations, 21.8% for Seattle criteria and 6.8% for international recommendations. International recommendations provided a positive (+LR) and negative (−LR) post-test likelihood ratio of 9.0 (95% CI 5.1 to 13.1) and 0.4 (95% CI 0.2 to 0.7), respectively.

Conclusion In Arab and black male paediatric athletes, new international recommendations outperform both the Seattle criteria and 2010 ESC recommendations, reducing false positive rates, while yielding a ‘fair’ diagnostic accuracy for cardiac pathology that may predispose to SCA/D. In clinical context, the ‘chance’ of detecting cardiac pathology within a paediatric male athlete with a positive ECG (+LR=9.0) was 8.3%, whereas a negative ECG (−LR=0.4) was 0.4%.

  • Ecg/electrocardiogram

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  • Contributors GMC and MGW contributed to the conception and design of this manuscript. GMC and NRR undertook intraobserver reliability. GMC analysed the data. All authors contributed to data interpretation. GMC and MGW wrote the manuscript. NRR, GP, VW, CA, SS, KPG and DO critically revised the manuscript for important intellectual content. MGW is the author of correspondence.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Ethics approval Ethics approval was provided by Anti-Doping Laboratory Qatar (IRB #E2013000003 and #E20140000012), with all parents or guardians providing informed consent.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice Since this article was first published online, the use of GCJM has been updated to read GMC.