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Seattle criteria classifying the normal and abnormal electrocardiogram findings in athletes

Seattle criteria classifying the normal and abnormal electrocardiogram findings in athletes
Normal ECG findings in athletes
  1. Sinus bradycardia (≥30 bpm)
  1. Sinus arrhythmia
  1. Ectopic atrial rhythm
  1. Junctional escape rhythm
  1. 1° AV block (PR interval >200 ms)
  1. Mobitz Type I (Wenckebach) 2° AV block
  1. Incomplete RBBB
  1. Isolated QRS voltage criteria for LVH
    • Except: QRS voltage criteria for LVH occurring with any nonvoltage criteria for LVH such as left atrial enlargement, left axis deviation, ST-segment depression, T-wave inversion, or pathological Q waves
  1. Early repolarization (ST elevation, J-point elevation, J waves, or terminal QRS slurring)
  1. Convex ("domed") ST-segment elevation combined with T-wave inversion in leads V1 to V4 in Black/African athletes
These common training-related ECG alterations are physiological adaptations to regular exercise, considered normal variants in athletes and do not require further evaluation in asymptomatic athletes
Abnormal ECG findings in athletes
Abnormal ECG finding Definition
T-wave inversion >1 mm in depth in 2 or more leads V2 to V6, II and aVF, or I and aVL (excludes III, aVR, and V1)
ST segment depression ≥0.5 mm in depth in 2 or more leads
Pathologic Q waves >3 mm in depth or >40 ms in duration in 2 or more leads (except for III and aVR)
Complete left bundle branch block QRS ≥120 ms, predominantly negative QRS complex in lead V1 (QS or rS), and upright monophasic R wave in leads I and V6
Intraventricular conduction delay Any QRS duration ≥140 ms
Left axis deviation –30° to –90°
Left atrial enlargement Prolonged P wave duration of >120 ms in leads I or II with negative portion of the P wave ≥1 mm in depth and ≥40 ms in duration in lead V1
Right ventricular hypertrophy pattern R-V1+S-V5 >10.5 mm AND right axis deviation >120°
Ventricular pre-excitation PR interval <120 ms with a delta wave (slurred upstroke in the QRS complex) and wide QRS (>120 ms)
Long QT interval*

QTc ≥470 ms (male)

QTc ≥480 ms (female)

QTc ≥500 ms (marked QT prolongation)
Short QT interval* QTc ≤320 ms
Brugada-like ECG pattern High take-off and downsloping ST-segment elevation followed by a negative T wave in ≥2 leads in V1 to V3
Profound sinus bradycardia <30 bpm or sinus pauses ≥3 s
Atrial tachyarrhythmias Supraventricular tachycardia, atrial fibrillation, atrial flutter
Premature ventricular contractions ≥2 PVCs per 10 s tracing
Ventricular arrhythmias Couplets, triplets, and nonsustained ventricular tachycardia

AV: atrioventricular; bpm: beats per minute; ECG: electrocardiogram; LVH: left ventricular hypertrophy; PVC: premature ventricular contraction; RBBB: right bundle branch block.

* The QT interval corrected for heart rate is ideally measured with heart rates of 60 to 90 bpm. Consider repeating the ECG after mild aerobic activity for borderline or abnormal QTc values with a heart rate <50 bpm.
From: Drezner JA, Ackerman MJ, Anderson J, et al. Electrocardiographic interpretation in athletes: The "Seattle Criteria". Br J Sports Med 2013; 47:123. Reproduced with permission from BMJ Publishing Group Ltd. Copyright © 2013.
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