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Electrocardiographic interpretation in athletes: the ‘ Seattle Criteria’

Article: Electrocardiographic interpretation in athletes: the ‘Seattle Criteria’ (Drezner JA, et al. British journal of Sports Medicine 2013;47:122-124. Doi:10.1136/bjsports-2012-092067.

Written by : Genevieve Rochette Gratton , MD, CCFP

Sudden cardiac death is one of the most tragic events for athletes, and is the leading cause of death for individuals participating in sports. Most of these events are associated with underlying cardiomyopathies and primary electrical diseases, and it is controversial if ECGs should be used for screening purposes to prevent sudden cardiac death. This controversy is mainly related to a high rate of false-positive interpretations from physicians not adequately trained to read athlete’s ECGs, which leads to further unnecessary investigations. Intense athletic training commonly leads to benign physiological changes due to cardiac adaptation and remodelling that can alter the ECG and be mistaken for abnormalities. The ‘Seattle Criteria’ were created to help physicians distinguish normal from abnormal ECG finding in athletes.2006_Pro_Bowl_tackle

Normal ECG findings in athletes:

  • Sinus bradycardia ≥30 bpm
  • Sinus arrhythmia
  • Ectopic atrial rhythm
  • 1° AV block (PR interval >200 ms)
  • Mobitz Type I (Wenckebach) 2°AV block
  • Incomplete RBBB
  • Isolated QRS voltage criteria for LVH*
  • Early repolarisation (ST elevation, J-point elevation, J-waves or terminal QRS slurring)
  • Convex (‘domed’) ST segment elevation combined with T-wave inversion in leads V1-V4 in black/African athletes

Abnormal ECG findings in athletes*

  • T-wave inversion
  • ST Segment depression
  • Pathologic Q waves
  • Complete LBBB
  • Intraventricular conduction delay
  • Left axis deviation (-30° to -90°)
  • Left atrial enlargement
  • Right ventricular hypertrophy pattern
  • Ventricular pre-excitation
  • Long QT interval
  • Short QT interval (QTc≤320ms)
  • Brugada-like ECG pattern
  • Profound sinus bradycardia
  • Atrial tachyarrhythmias
  • Premature ventricular contractions
  • Ventricular arrhythmias

*Please refer to article for more precise definition of ECG findings

Even though there are some limitations to the Seattle Criteria, they remain very helpful to identify normal findings in athlete ECGs, to avoid false-positive results, improve precision of ECG interpretations, and enhance cardiovascular care with the intent to prevent sudden cardiac death in athletes.


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