ECG interpretation for pre-participation screening in athletes

The role of electrocardiography (ECG) in pre-participation screening (PPS) has long been debated, but accumulating evidence supports its importance in detecting cardiovascular diseases associated with sudden cardiac death (SCD). Its systematic use has contributed to a reduction in SCD incidence among athletes. Over the past two decades, interpretation standards have evolved, culminating in the International Criteria, which classify ECG findings as normal, borderline, or abnormal. Training-related and vagal tone-related changes are recognized as physiological variants, borderline alterations represent intermediate findings that require careful contextual interpretation, and abnormal patterns constitute true red flags that always warrant further investigation. Additional challenges concern special populations, including children, women, and master athletes, where training-induced remodeling and ECG expression may differ from young male cohorts on which the current criteria are based. While the International Criteria remain the reference framework, future updates are needed to refine thresholds, incorporate emerging evidence, and adapt to diverse athletic populations, with the ultimate goal of improving diagnostic accuracy and preventing SCD.