Key result
Multiple borderline ECG criteria and ventricular ectopy fail to identify major cardiac pathology in athletes.
Why the study?
The diagnostic yield and clinical implications of borderline ECG findings and ectopic beats under the 2017 International Criteria required evaluation in elite football players.
Does the presence of borderline ECG changes or ectopic beats predict major or minor cardiac pathology in elite football players?
Cohort (n=17,685)
Yes
Does the presence of borderline ECG changes or ectopic beats predict major or minor cardiac pathology in elite football players?
Borderline ECG criteria and ventricular ectopy are poor discriminators for cardiac pathology in athletes, suggesting that even ≥2 borderline findings may not warrant further evaluation.
Answers are grounded in this paper and cite their sources.
Should not yet alter screening in athletes; leaves open whether 2017 criteria require revision for borderline findings.
Objective To evaluate the diagnostic yield and clinical implications of so-called ‘borderline’ ECG findings and ectopic beats in elite football players, in accordance with the 2017 International Criteria (IC17) 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. Borderline ECG changes were classified according to the IC17. Supraventricular and ventricular ectopic 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 1389 (7.9%) athletes (8.8% males, 2.6% females; p<0.001), with right atrial enlargement being the most frequently observed pattern (5.5%). Major cardiac pathology was incidentally identified in 2 (1.43%) athletes with isolated left atrial enlargement, compared with 9 (0.06%) athletes with normal ECGs (p=0.004), including 1 case of an anomalous coronary origin and another case with significant aortic root dilatation—both unrelated to the ECG findings. All other borderline patterns as well as ectopy did not reveal any major pathology. No major conditions were identified in 42 athletes with isolated ≥2 borderline ECG findings. Minor cardiac pathology was identified in 18 (1.41%) athletes with isolated borderline findings and in 3 (2.07%) athletes with isolated ectopy. When ≥2 borderline findings were present, 2.38% athletes revealed minor pathology (p=0.463). Minor cardiac pathology was found in 212 (1.34%) of athletes with normal ECGs (p=0.836). Conclusion Borderline ECG criteria in the IC17 and ventricular ectopy are poor discriminators for major and minor cardiac pathology in athletes. Borderline changes including ≥2 findings do not warrant further evaluation and could be considered normal findings in future iterations of ECG interpretation criteria in athletes.
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Yamagata et al. (2026) conducted a cohort in Elite athletes undergoing cardiac screening (n=17,685). Borderline ECG findings (LAE, RAE, LAD, RAD, RBBB) and ectopic beats vs. Normal ECGs was evaluated on Major cardiac pathology (p=0.004). Borderline ECG criteria and ventricular ectopy are poor discriminators for cardiac pathology in athletes, with no major conditions identified in athletes with ≥2 borderline findings.
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