Evolving interpretation of the athlete's electrocardiogram: From European Society of Cardiology and Stanford criteria, to Seattle criteria and beyond

Electrocardiographic (ECG) pre-participation screening can prevent sudden cardiac death in the athletes by early diagnosis and disqualification of affected individuals. Interpretation of the athlete's ECG should be based on specific criteria, because ECG changes that would be considered abnormal in the untrained population may develop in trained athletes as a physiologic and benign consequence of the heart's adaptation to exercise. In 2010, a stem document from the Section of Sports Cardiology of the European Society of Cardiology (ESC) proposed to classify the athlete's ECG changes according to the prevalence, relation to exercise training, association with an increased risk of cardiovascular disease and need for further investigations into two groups: “common and training-related” (Group 1) and “uncommon and training-unrelated” (Group 2). Over the last years, several efforts have been made to refine the ESC criteria for interpretation of the athlete's ECG in order to improve specificity maintaining good sensitivity, especially among elite and Afro-Caribbean athletes, which show the highest rate of false positives Group 2 ECG abnormalities. However, the balance between improvement in specificity and loss of sensitivity should be evaluated keeping in mind that the primary aim of the screening program is to save the athlete's lives rather than money.