Electrocardiographic interpretation in athletes: the ‘Seattle Criteria’: Table 1

Abstract

Sudden cardiac death (SCD) is the leading cause of death in athletes during sport. Whether obtained for screening or diagnostic purposes, an ECG increases the ability to detect underlying cardiovascular conditions that may increase the risk for SCD. In most countries, there is a shortage of physician expertise in the interpretation of an athlete's ECG. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from abnormal findings suggestive of pathology. On 13-14 February 2012, an international group of experts in sports cardiology and sports medicine convened in Seattle, Washington, to define contemporary standards for ECG interpretation in athletes. The objective of the meeting was to develop a comprehensive training resource to help physicians distinguish normal ECG alterations in athletes from abnormal ECG findings that require additional evaluation for conditions associated with SCD.

Recognition and Significance of Pathological T-Wave Inversions in Athletes

“…Athletes presenting with physiological TWI in leads III, aVR, and V1, and in V1 through V4 when TWI was preceeded by convexed/ domed ST segment in Afro-Caribbean athletes only were not included ( Figure 2). 4,6,16 …”

Common electrocardiogram variations pre‐ and post‐marathon

“…With respect to our case report, each of the results considered above represent normal electrocardiographic findings in athletes, with the exception of the ischemic ST changes observed in a single participant 15. In particular, the presence of ECG findings such as incomplete right bundle branch block, QRS complexes meeting voltage criteria for left ventricular hypertrophy and alterations in the usual electrocardiographic pattern for ventricular repolarization have the potential, when taken out of context, to prompt misguided concern on the part of healthcare providers.…”

Signs of RV overload on the athlete’s ECG

“…Another important finding on the ECG in this case was the presence of 2 premature ventricular contractions, which is considered abnormal in a 10 s ECG recording and should trigger further investigation [4]. In patients with RVOT tachycardia, a benign condition not associated with structural ventricular abnormalities, the QRS complex of the ventricular ectopy will invariably have an LBBB morphology that is positive in the inferior leads II, III, and AVF and almost always negative in aVL [19].…”

“…Although these adaptations are generally considered the expression of adaptive physiology in athletes, it is often challenging to reliably distinguish these from abnormal ECG findings related to potentially lethal cardiovascular conditions due to their phenotypic overlap. For this purpose, ECG interpretation guidelines classify ECG changes as either those which are common and training related ("group 1") or those thought to be uncommon, training unrelated, and which warrant further investigation to exclude cardiac pathology ("group 2") [3,4]. Nevertheless, recent data have shown that even group 2 ECG findings are not so uncommon in highly-trained endurance athletes, particularly those ECG features suggestive of right ventricular (RV) pathology such as deep T-wave inversion (TWI) in the right precordial leads and voltage criteria for RV hypertrophy [2].…”