Appropriate interpretation of the athlete's electrocardiogram saves lives as well as moneyThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

In the Italian screening protocol, the ECG is evaluated in light of the athlete's gender, age, race, family history of cardiovascular disease and/or sudden death, clinical symptoms, and physical examination. In asymptomatic athletes with a negative family history, ECG changes due to cardiac adaptation to physical exertion (Group 1) do not cause alarm and allow eligibility to participate in competitive sports without additional evaluation. Further diagnostic work-up is limited to the subset of athletes with ECG changes which potentially reflect underlying heart disease (Group 2), and/or those with a positive medical history or an abnormal physical examination, resulting in a considerable cost savings. This screening algorithm, which has been used for pre-participation evaluation of millions of Italian athletes over a 25-year period, has provided adequate sensitivity and specificity for detection of athletes affected by potentially dangerous cardiomyopathy or arrhythmia at risk of athletic field death and has led to a substantial reduction of mortality of young competitive athletes (by ∼90%), mostly by preventing sudden death from cardiomyopathy.