Guide to the female student athlete ECG: A comprehensive study of 3466 young, racially diverse athletes


      • Sex specific criteria for athlete ECG interpretation is needed
      • The addition of age, race, and ethnicity can provide nuanced ECG interpretation
      • Future guidelines may want to include extremes of RS voltage as abnormalities



      : The 12-lead electrocardiogram (ECG) is used in the preparticipation screening exam for athletes. Despite known differences in ECG findings by sex, only QTc prolongation is given a sex specific threshold. We hypothesize that our large dataset – with diversity in age, race, and sport participation – can be utilized to improve ECG screening in female student athletes.


      : Computerized 12-lead ECGs were recorded and analyzed in female athletes who underwent preparticipation screening exam between 06/2010 and 09/2021. The quantitative, empirical 2017 international criteria for electrocardiographic interpretation were compared to either the 99th percentile in our cohort or the percentile that corresponded to the known disease prevalence.


      : Of 3466 female athletes with ECGs as part of preparticipation screening exam, the 2017 international criteria classified 2.1% of athletes with at least one ECG abnormality requiring cardiological evaluation. Rates were similar across age, race/ethnicity, and sporting discipline. Using ranges based on our population, 2.7% of athletes would require additional workup. Surprisingly, ST depression up to 0.03 mV was a normal finding in this cohort. If RS voltage extremes were considered findings requiring follow up, an additional 9.6% of the athlete population would be flagged using current definitions. This number decreases to 2.7% if using the 99th percentile in this cohort.


      : These results highlight a difference in the reported prevalence of ECG abnormalities when comparing empirically derived thresholds to statistically derived ranges. Consideration of new metrics specific to the female athlete population has the potential to further refine athlete ECG screening.


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