Should Electrocardiograms Be Used as Part of a... : Strength & Conditioning Journal (2025)

Scott Riewald, PhD, CSCS

Column Editor

Every year, we hear at least one story of a young athlete who died on the athletic field, the product of some previously undiagnosed cardiac condition. The results are tragic, and we are often left asking why this happened and if there was any way these all could have been prevented. When asked this question, many people immediately think of the preparticipation physical examination (PPE), which is required by many sports organizations, and look to see if a test could be performed to screen athletes and identify risks before they step on the field of play. The PPE, which typically requires an athlete to undergo a physical examination as well as complete a medical history questionnaire, is used to identify potential injuries or illnesses that may preclude an athlete from participating safely in the athletic program. Yet unless an athlete has a family history to suggest there may be a risk of cardiovascular disease, most cardiac conditions will fly under the radar with a “standard” PPE.

Recently, more and more individuals and organizations have been advocating the use of electrocardiograms (ECGs or EKGs), or even more expensive echocardiograms, as part of the preparticipation screening. Electrocardiograms provide information specific to the working of the heart-information that can help increase the chances of detecting a cardiac condition. On paper, inclusion of an ECG makes perfect sense, but keep in mind there are trade-offs that must be taken into account when deciding to include an ECG as part of the PPE. Recently, in Medicine and Science in Sports and Exercise, Lawless and Best (¹) put together a summary of the research related to the effectiveness and success of using ECGs to identify cardiac risk factors in young athletes.

In reviewing the available literature, the authors highlight a number of important results that should be taken into consideration when weighing the pros and cons of including such a test in a PPE. Some of the points made from the research include

• Some of the most comprehensive work with ECGs has been done in Italy, where comprehensive screening has reduced the incidence of sudden cardiac death by 89% over a 26-year period.
• Electrocardiograms can accurately diagnose between 75 and 95% of the athletes with hypertrophic cardiac myopathy, a condition characterized by a thickening of the heart's walls and one that has received a lot of press due to several recent athlete deaths.
• The inclusion of an ECG can increase the overall sensitivity of a PPE (the proportion of athletes with a heart condition who are correctly identified by the test) considerably over the “standard” PPE-from 2.5 to 6% to as much as 51 to 95%-depending on the type of underlying condition and the population being evaluated.
• Yet at the same time, false positives can be as high as 40%, meaning athletes who do not truly have a heart condition could be excluded from participation based on a false finding, and
• Even when athletes demonstrate a normal or only mildly abnormal ECG, there is still as much as a 4 to 5% chance, there is an undetected underlying heart condition (so, the test still will not identify everyone with a heart condition).
• Most of the available data have been collected from a homogeneous pool of subjects, predominantly adult Caucasians. There is reason to believe that ECGs in athletic African Americans may differ from these data, and drawing conclusions from the available data may lead to improper diagnoses in this group of athletes. Additionally, adults can show markedly different ECGs compared to youth and adolescents. Many of the “recognizable features” that suggest an underlying heart condition, in fact, may not present themselves until adulthood.
• The heart responds and adapts to exercise, and it is not uncommon to see “changes” in the ECGs of well-trained athletes. Are these “abnormalities” a reflection of a heart condition or do they reflect a normal adaptation to exercise? Also, data indicate that the “normal” changes may be more pronounced in some sports compared with others, making interpretation increasingly difficult.
• There presently is no “gold standard” for evaluating ECGs, and it is not uncommon for health care professionals in the United States to analyze the same ECG and come away with different conclusions about the health of the athlete.
• There is also the cost associated with conducting ECGs and any subsequent more discriminating tests that will need to be conducted to verify the results of a positive ECG.

This is a lot to consider when making a decision about whether to include an ECG as part of a PPE. On the one hand, you may feel that athlete's health should trump all other decisions. But if you are requiring a test to be a part of a PPE, you would also like that test to have 100% accuracy in diagnosing underlying heart conditions. Taking these factors into account, the American Heart Association has recommended that ECGs need not be a mandatory part of a PPE screening for athletes. They cite the costs associated with testing a large number of athletes, the number of false positives (as well as the costs associated with further evaluating false positives), the lack of randomized controlled studies to demonstrate the superiority of the ECG over a traditional PPE, the lack of normative data in youth and certain demographics, and the variability inherent to ECG interpretation as the primary factors motivating their recommendation.

As a strength and conditioning coach, where do you stand on this issue? Where should you stand? No one can make that decision for you, but it is your responsibility to at least consider the question and how you want to address this topic with the athletes you work with. If you choose to make an ECG a part of your PPE, the authors of this study provide a good “decision” tree to help coaches, athletes, and physicians come to a decision about how athletes should be treated based on the results obtained from the athlete's medical history report and the ECG results and whether additional diagnostic testing should be used. While the summary presented in the Strength and Conditioning Journal provides an overview of the topic, you are encouraged to read the full article to more fully understand the depth of the research and the implications it has on the field of strength and conditioning as well as athletic participation.

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