Are the QRS duration and ST depression cut-points from the Seattle criteria too conservative?

• Screening athletes with ECGs is aimed at identifying individuals with cardiac conditions predisposing them to sudden cardiac death.
• Seattle criteria highlight QRS duration greater than 140 ms and ST segment depression in two or more leads greater than 50 μV as two abnormal ECG patterns requiring further evaluation prior to participation.
• QRS duration greater than 120 ms and ST segment depression in the lateral leads have been demonstrated in epidemiological and clinical studies to have risk for cardiac death.
• Changing the Seattle criteria QRS duration cut-point to 125 ms could potentially increase sensitivity of the screening ECG, without an increase in false-positives since the prevalence of QRS duration greater than 125 ms is low.
• Changing the ST segment depression cut-point to 25 μV would increase false-positives and could not be justified at this time though focusing on the lateral leads and considering slope should be considered in future studies.

BackgroundScreening athletes with ECGs is aimed at identifying "at-risk" individuals who may have a cardiac condition predisposing them to sudden cardiac death. The Seattle criteria highlight QRS duration greater than 140 ms and ST segment depression in two or more leads greater than 50 μV as two abnormal ECG patterns associated with sudden cardiac death.MethodsHigh school, college, and professional athletes underwent 12 lead ECGs as part of routine pre-participation physicals. Prevalence of prolonged QRS duration was measured using cut-points of 120, 125, 130, and 140 ms. ST segment depression was measured in all leads except leads III, aVR, and V1 with cut-points of 25 μV and 50 μV.ResultsBetween June 2010 and November 2013, 1595 participants including 297 (167 male, mean age 16.2) high school athletes, 1016 (541 male, mean age 18.8) college athletes, and 282 (mean age 26.6) male professional athletes underwent screening with an ECG. Only 3 athletes (0.2%) had a QRS duration greater than 125 ms. ST segment depression in two or more leads greater than 50 μV was uncommon (0.8%), while the prevalence of ST segment depression in two or more leads increased to 4.5% with a cut-point of 25 μV.ConclusionChanging the QRS duration cut-point to 125 ms would increase the sensitivity of the screening ECG, without a significant increase in false-positives. However, changing the ST segment depression cut-point to 25 μV would lead to a significant increase in false-positives and would therefore not be justified.