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ECG interpretation in athletes is a required skill for the sports medicine physician. Whether used for screening or diagnostic purposes, ECG facilitates the detection of conditions at risk for sudden cardiac death (SCD). ECG interpretation standards have evolved over the last decade as scientific studies improved the division of physiological from pathological ECG changes. The Seattle Criteria (2013) provided consensus recommendations by an international panel of experts in sports cardiology and emerged as a practical guideline to improve ECG interpretation accuracy.1 In 2017, the International Criteria was released by the same expert panel and intended to supersede prior guidelines as the current standard for ECG interpretation in athletes.2 Each revision of ECG standards has improved specificity without compromising sensitivity for ECG-detectable pathological conditions associated with SCD.3–5 In a cohort of 5258 college athletes from the USA, application of the International Criteria lowered the false-positive rate compared with the Seattle Criteria from 2.8% to just 1.3%.3 Likewise, in a cohort of 11 168 adolescent soccer players from the UK, the total number of athletes with an abnormal ECG was reduced 57% by moving from the Seattle Criteria (4.3%) to the International Criteria (1.8%).4
Differences between the Seattle and International Criteria
The most substantive change is the introduction of a ‘yellow’ box or list of borderline ECG findings in which two or more borderline findings …
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