Kentaro Yamagata, Jonathan A Drezner, Dan Augustine, Michael Bowes, Paul Clift, Robert M Cooper, Antoinette Kenny, David Oxborough, Kiran Patel, Dhrubo Rakhit, David Ripley, Tristan Ramcharan, Georgina K Stebbings, Amanda M Varnava, John Walsh, Zaheer Yousef, Charlotte M Cowie, Jamie S McPhee, Sanjay Sharma, Aneil Malhotra
Borderline ECG criteria in the IC17 and ventricular ectopy are poor discriminators for major and minor cardiac pathology in athletes. Borderline changes including ≥2 findings do not warrant further evaluation and could be considered normal findings in future iterations of ECG interpretation criteria in athletes.
OBJECTIVE: To evaluate the diagnostic yield and clinical implications of so-called 'borderline' ECG findings and ectopic beats in elite football players, in accordance with the 2017 International Criteria (IC17) for ECG interpretation in athletes.
METHODS: A total of 17 685 professional footballers (84.7% males) underwent cardiac screening including a 12-lead ECG and echocardiography between 2017 and 2024. Borderline ECG changes were classified according to the IC17. Supraventricular and ventricular ectopic beats were also analysed. Prevalence of cardiac pathology (major and minor) among athletes with borderline changes was compared with those athletes with normal ECGs.
RESULTS: Borderline ECG findings were present in 1389 (7.9%) athletes (8.8% males, 2.6% females; p<0.001), with right atrial enlargement being the most frequently observed pattern (5.5%). Major cardiac pathology was incidentally identified in 2 (1.43%) athletes with isolated left atrial enlargement, compared with 9 (0.06%) athletes with normal ECGs (p=0.004), including 1 case of an anomalous coronary origin and another case with significant aortic root dilatation-both unrelated to the ECG findings. All other borderline patterns as well as ectopy did not reveal any major pathology. No major conditions were identified in 42 athletes with isolated ≥2 borderline ECG findings. Minor cardiac pathology was identified in 18 (1.41%) athletes with isolated borderline findings and in 3 (2.07%) athletes with isolated ectopy. When ≥2 borderline findings were present, 2.38% athletes revealed minor pathology (p=0.463). Minor cardiac pathology was found in 212 (1.34%) of athletes with normal ECGs (p=0.836).
CONCLUSION: Borderline ECG criteria in the IC17 and ventricular ectopy are poor discriminators for major and minor cardiac pathology in athletes. Borderline changes including ≥2 findings do not warrant further evaluation and could be considered normal findings in future iterations of ECG interpretation criteria in athletes.