Borderline ECG changes are poor discriminators for cardiac pathology, with isolated left atrial enlargement showing a 1.43% prevalence of major pathology vs 0.07% for normal ECGs (p=0.006).
Cross-Sectional (n=17,685)
Do borderline ECG changes or ectopic beats predict underlying cardiac pathology in elite football players?
Borderline ECG changes and ectopy in elite athletes have very low sensitivity for detecting cardiac pathology, suggesting they could be considered normal findings in future screening criteria.
Absolute Event Rate: 1.43% vs 0.07%
p-value: p=0.006
Abstract Objective To evaluate the diagnostic yield and clinical implications of so-called ‘borderline’ electrocardiographic (ECG) findings and ectopic beats in elite football players, in accordance with the 2017 International Criteria (IC) for ECG Interpretation in Athletes. Methods A total of 17,685 professional footballers (84.7% males) underwent cardiac screening including a 12-lead ECG and echocardiography between 2017 and 2024 within the English Football Association programme. Borderline ECG changes were classified according to the 2017 IC, namely left atrial enlargement (LAE), right atrial enlargement (RAE), left axis deviation (LAD), right axis deviation (RAD) and complete right bundle branch block (RBBB). Supraventricular ectopic (SVE) and ventricular ectopic (VE) beats were also analysed. Prevalence of cardiac pathology (major and minor) among athletes with borderline changes was compared with those athletes with normal ECGs. Results Borderline ECG findings were present in 8.3% athletes (9.3% males, 2.6% females; p0.001), with right atrial enlargement (RAE) being the most frequently observed pattern (5.5%). Major cardiac pathology was identified in two (0.15%) athletes with isolated LAE only (p=0.006), which was one (0.08%) case of an anomalous coronary origin and another with significant aortic root dilatation, corresponding to a prevalence of 1.43% in athletes with isolated LAE versus 0.07% in those with normal ECGs (p=0.006). All other borderline patterns of LAD, RAD, RAE, and RBBB, as well ectopy did not reveal any major pathology. Even when ≥2 borderline changes were present, there were no major conditions identified. Minor cardiac pathology was identified in 18 (1.4%) athletes among athletes with isolated borderline findings and in 3 (4.5%) among athletes with either single or multiple ventricular ectopy. When ≥2 borderline changes were present, 2.4% athletes revealed minor pathology. In contrast, SVE was not associated with an underlying cardiac condition. Sensitivity of all borderline ECG patterns for detecting any cardiac pathology was low (5%), though specificity exceeded 90%. LAE was the highest performing ECG finding with a sensitivity 2.9% for detecting major cardiac pathology. Conclusion Borderline ECG criteria of the 2017 IC and ectopy are poor discriminators for major and minor cardiac pathology in athletes. Isolated LAE had a marginally better sensitivity for major disease but this was likely coincidental given the nature of conditions identified. Borderline changes themselves should therefore not warrant further evaluation and could be considered normal findings in future iterations of ECG interpretation in athletes.For image description, please refer to the figure legend and surrounding text. For image description, please refer to the figure legend and surrounding text.
Yamagata et al. (Mon,) conducted a cross-sectional in Cardiac screening in elite football players (n=17,685). Borderline ECG changes and ectopic beats vs. Normal ECGs was evaluated on Major cardiac pathology (p=0.006). Borderline ECG changes are poor discriminators for cardiac pathology, with isolated left atrial enlargement showing a 1.43% prevalence of major pathology vs 0.07% for normal ECGs (p=0.006).
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