A decade of athlete ECG criteria: Where we’ve come and where we’re going

•ECG interpretation in athletes and highly active people presents numerous challenges.•Adaptations of the cardiovascular system that occur in response to exercise training commonly manifest on the 12-lead electrocardiogram and may be confused with patterns that are indicative of underlying cardiovascular disease.•Considerable efforts have been committed to the development of athlete specific ECG criteria for use in both research and clinical settings.•A historical overview of athlete ECG criteria development and revision provides a valuable framework for understanding remaining issues of uncertainty that plague this field.

Competitive athletes and highly active individuals commonly develop cardiovascular adaptations. Underlying features of exercise-induced cardiac remodeling often manifest as distinct patterns on the 12-lead electrocardiogram (ECG). Considerable effort has been directed toward defining the scope of ECG abnormalities in this population and numerous criteria have been proposed for the task of differentiating benign athletic ECG changes from patterns suggestive of underlying cardiovascular disease. This review will provide a historical overview of athlete ECG criteria development with a final emphasis on remaining areas of scientific and clinical uncertainty.