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Accuracy of the 2017 international recommendations for clinicians who interpret adolescent athletes’ ECGs: a cohort study of 11 168 British white and black soccer players
  1. Aneil Malhotra1,
  2. Harshil Dhutia1,
  3. Tee-Joo Yeo1,2,
  4. Gherardo Finocchiaro1,
  5. Sabiha Gati1,3,
  6. Paulo Bulleros1,
  7. Zephyr Fanton1,
  8. Efstathios Papatheodorou1,
  9. Chris Miles1,
  10. Tracey Keteepe-Arachi,
  11. Joyee Basu1,
  12. Gemma Parry-Williams1,
  13. Keerthi Prakash1,
  14. Belinda Gray1,
  15. Andrew D'Silva1,
  16. Bode Ensam1,
  17. Elijah Behr1,
  18. Maite Tome1,
  19. Michael Papadakis1,
  20. Sanjay Sharma1
  1. 1Cardiology Clinical Academic Group, St. George’s University of London, London, UK
  2. 2National University Heart Centre, Singapore, Singapore
  3. 3East and North Hertfordshire NHS Trust, Lister Hospital, Stevenage, UK
  1. Correspondence to Professor Sanjay Sharma, Cardiology Clinical Academic Group, St. George's University of London, London SW17 0RE, UK; sasharma{at}


Aim To investigate the accuracy of the recently published international recommendations for ECG interpretation in young athletes in a large cohort of white and black adolescent soccer players.

Methods 11 168 soccer players (mean age 16.4±1.2 years) were evaluated with a health questionnaire, ECG and echocardiogram; 10 581 (95%) of the players were male and 10 163 (91%) were white. ECGs were retrospectively analysed according to (1) the 2010 European Society of Cardiology (ESC) recommendations, (2) Seattle criteria, (3) refined criteria and (4) the international recommendations for ECG interpretation in young athletes.

Results The ESC recommendations resulted in a higher number of abnormal ECGs compared with the Seattle, refined and international criteria (13.2%, 4.3%, 2.9% and 1.8%, respectively). All four criteria were associated with a higher prevalence of abnormal ECGs in black athletes compared with white athletes (ESC: 16.2% vs 12.9%; Seattle: 5.9% vs 4.2%; refined: 3.8% vs 2.8%; international 3.6% vs 1.6%; p<0.001 each). Compared with ESC recommendations, the Seattle, refined and international criteria identified a lower number of abnormal ECGs—by 67%, 78% and 86%, respectively. All four criteria identified 36 (86%) of 42 athletes with serious cardiac pathology. Compared with ESC recommendations, the Seattle criteria improved specificity from 87% to 96% in white athletes and 84% to 94% in black athletes. The international recommendations demonstrated the highest specificity for white (99%) and black (97%) athletes and a sensitivity of 86%.

Conclusions The 2017 international recommendations for ECG interpretation in young athletes can be applied to adolescent athletes to detect serious cardiac disease. These recommendations perform more effectively than previous ECG criteria in both white and black adolescent soccer players.

  • adolescent athlete
  • arrhythmogenic right ventricular cardiomyopathy
  • ecg criteria
  • hypertrophic cardiomyopathy
  • screening

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  • Contributors AM designed data collection tools, monitored data collection, cleaned and analysed the data, and drafted and revised the manuscript. HD, SG and GF designed data collection tools and drafted the manuscript. T-JY, CM, TK-A and JB monitored data collection and analysed the data. PB, ZF, EP, BE, BG, GP-W and AD contributed to data collection. MT, EB and MP revised the manuscript. SS initiated the project, monitored data collection for the whole study, analysed the data, and drafted and revised the paper. SS is the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The project was reviewed and approved from an ethics perspective by the St. George’s Joint Research and Enterprise Office.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No data are available.