The ECG and the pre-participation examination of young athletes.

This is an exciting time for sports cardiology and all concerned with the cardiovascular health of young athletes. Progress had been delayed by the exaggerated concern that the ECG would be mandated as part of the currently recommended physical exam and history pre-participation exam (PPE) in the US as in parts of Europe [1]. This concern was misplaced since current recommendations for the elements of the PPE by major American medical associations have never been mandated and in fact are inconsistently applied across the US [2]. Rather new research has led to an improved understanding of the diseases that put athletes at risk for sudden cardiac death (SCD) [3] and how the ECG can be utilized to optimally recognize these diseases[4].Muchofthenewdatahascomefromlargedatasets ofathletesstudiedintheUK(StGeorgesUniversityofLondon), Qatar (Aspetar Sports Medicine Hospital) and the University of Washington. This has culminated in the recent 2nd Seattle ECG Interpretation in Athletes: Seattle Summit 2015 where a group of experts refined the criteria lowering the false positive rate to roughly 3%. This is considerably lower than the false positive rate of the AHA 14 points (about 25%) [5]. With the volume of this new ECG research made possible by a growing cadre of researchers, the editors felt that a special issue devoted to the ECG of athletes was appropriate. This issue is divided into two parts: first, ten articles regarding general issues related to ECG screening of athletes and the second, ten articles on specific ECG waveforms. Part 1 starts with arguments against adding the ECG to the standard PPE followed by best practices for ECG screening in the young and a meta-analysis comparing the elements of the PPE. Three papers follow reviewing ECG criteria developed specifically for athletes. The methodology of screening is considered in papers supporting nurses and physician assistants in the PPE process and now volunteers perform ECGs. Finally, the psychological impact of screening is considered and improving cardiovascular screening in older amateur athletes is covered. Part 2 presents issues regarding specific ECG waveforms including WPW, right ventricular overload, bundle branch block, left ventricular hypertrophy (LVH), T wave abnormalities, early repolarization, computerized ECG measurements and Q wave dimensions. Data supporting WPW as a major concern for SCD in young athletes are presented along with the argument we need to be more pro-active when it is detected. Several papers support the decision that isolated R and S wave amplitude criteria should not be used to require evaluation prior to participation and the other components of traditional LVH (ST depression, T wave inversion, left atrial enlargement) should be of concern. The complex issues regarding T wave inversion relating to lead location and ST doming are nicely reviewed. The benign nature for athletes of all elements of early repolarization is presented hopefully protecting athletes from the ICD-early repolarization reflex. The importance of gathering digital ECG data to develop computer measured ECG waveform amplitudes and durations norms is presented in the last two papers. We are grateful to our authors who have been major contributors to the field of sports medicine and specifically regarding electrocardiography .W e are at ap oint where there is considerable interest in turning the debate upside down with the realization that the ECG could have greater screening value than the long recommended physical exam and history. Improvements in the ECG criteria for athletes and technological advances could support this paradigm shift. The NCAA appears to be poised to recommend the ECG as part of the PPE exam (http://www.wsj.com/articles/in-the-ncaa-a-push-to-reform