ECG interpretation in athletes by expert Sports Cardiologists and Non-Specialist Medical Professionals across Europe: A Survey from the European Association of Preventive Cardiology

Background We aimed to evaluate the real-world use of contemporary international ECG interpretation criteria in athletes, and to compare practices, clinical decision-making, and perceived barriers between specialist and non-specialist professionals across Europe. Methods Two sets of structured questionnaires were developed and distributed to either sports cardiologists or non-specialist professionals. Knowledge of international guidelines, experience in ECG interpretation, and confidence levels in clinical decision-making across various clinical scenarios were evaluated. An open-ended questionnaire was also developed to explore aspects of ECG interpretation, medicolegal issues, relevant legal frameworks across European countries, and personal thoughts on possible future revisions to the documents. The questionnaires were revised and edited by expert sports cardiologists, affiliated with EAPC. Data were analysed both quantitatively and qualitatively. Results A total of 242 participants across Europe were included; 66% were male and 57% worked in public hospitals. Non-specialists demonstrated uncertainty in standard definitions, classification systems, and key applications of ECG criteria. These findings highlight variability in preparticipation screening (PPS) practices and areas of uncertainty in clinical decision-making, alongside concerns regarding access to specialist services. Notably, 25% of specialists favoured a flexible interpretative approach beyond current standard criteria. The majority supported the need for updated guidance and improved description of specific ECG indices, including ventricular ectopy (83%), QRS fragmentation (83%), and low-amplitude QRS complexes (78%), alongside recognition of the potential role of artificial intelligence–based models. Gaps in knowledge, training, and practice were identified, and both groups emphasised medicolegal and pathway challenges. Conclusions This international survey provides a contemporary real-world overview of ECG interpretation and PPS practice in athletes across Europe and revealed substantial heterogeneity in access to services, training, interpretation uncertainty, referral pathways, and medico-legal frameworks.