Electrocardiogram interpretation in elite athletes: comparison of the 2017 and updated 2025 International Criteria

Background

Cardiac screening of athletes including an electrocardiogram (ECG) to identify conditions associated with sudden death has been widely adopted. The International Criteria 2017 (IC17)1 are the gold standard for athlete-specific ECG interpretation. Based on evolving science, the International Criteria were updated at an expert consensus summit in Seattle, USA in September 2025 (IC25).2

Aim

To compare the proportion of screening ECGs requiring further evaluation using the IC17 and updated IC25 criteria within a large cohort of elite athletes.

Methods

Screening records of elite and professional athletes were obtained from the Australasian Registry of ECGs of National Athletes (ARENA) project and previous cohort studies in Australia and New Zealand. Disciplines included summer and winter Olympic sports, soccer, Australian football, cricket and netball and were grouped according to the EAPC classification.3 ECGs were analysed according to IC17 and IC25 criteria and defined as abnormal if they had ≥1 abnormal or ≥2 borderline findings. Comparisons were made using Chi-square tests (p<0.05 considered significant).

Results

The first screening ECG from 8,111 athletes (47% female, mean age 20.0 ± 4.8 years) from 54 sports were included. The proportion of athletes requiring further evaluation based on ECG findings was 28% lower using the IC25 vs IC17 (1.6% vs 2.3%, p<0.0001). Both female and male athletes had lower abnormal rates using IC25 vs IC17 (female: 1.5% vs 2.1%, p<0.0001; male: 1.8% vs 2.4%, p<0.0001).

A total of 56 ECGs (0.69%) that were abnormal using IC17 became normal using IC25. Reclassification was more common in endurance compared to non-endurance athletes (1.5% vs 0.4%, p<0.0001). ECG changes accounting for this reduction comprised: isolated female athlete TWI V1-V3 (n=21, 38%, Fig 1), male athlete repolarisation pattern (J-point elevation ≥1mm with convex ST segment elevation and TWI confined to V1-V4, n=13, 23%; Fig 2), inferior TWI (n=14, 25%) and other (n=8, 14%).

There were 4 (0.05%) athletes requiring further evaluation using IC25, but not IC17, mainly due to a single premature ventricular contraction with non-inferior axis. Only one athlete with an abnormal ECG using IC17 but not IC25 (male athlete repolarisation pattern / ST depression isolated to aVL) had underlying pathology (hypertrophic cardiomyopathy) which was also identified by family history. No athletes with an ECG that was reclassified suffered major adverse cardiovascular events during 6.9 ± 0.4 years of follow-up.

Conclusions

Compared to the IC17, the IC25 consensus recommendations for ECG interpretation in athletes reduced the total abnormal ECG rate by 28%, thereby preventing 1/156 athletes from unnecessary further investigations.fig--1--esc--abstract.jpgfig--2--esc--abstract.jpg