ECG Screening in Athletes: A Systematic Review of Sport, Age, and Gender Variations.

Background: The electrocardiogram (ECG) screening in athletes is essential due to the unique cardiac adaptations induced by intensive training. However, differentiating between physiological adaptations and pathological abnormalities remains a significant challenge, particularly when considering variations across different sports, ages, and genders.

Methods: A systematic review of observational studies published between 2015 and 2025 was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted from 20 studies examining ECG changes in athletes across endurance, strength, and mixed sports, encompassing both adolescent and adult populations.

Results: Commonly observed ECG changes included increased QRS amplitude, T-wave inversions, and sinus bradycardia, particularly in endurance athletes, while strength-based athletes frequently exhibited left ventricular hypertrophy. Male athletes showed higher QRS voltages, longer QRS durations, and higher PR intervals, whereas female athletes demonstrated elevated resting heart rates and prolonged corrected QT interval (QTc) intervals. Adolescents who engaged in regular sports displayed fewer abnormal ECG findings than adults; however, high-intensity training in adolescent athletes was associated with right atrial enlargement and increased P-wave duration. Detraining effectively reversed certain ECG changes, including prolonged QT intervals and T-wave abnormalities, though these changes often reappeared upon resumption of intense training. Notably, de novo ECG abnormalities, such as T-wave inversions and ST-segment depression, were identified in athletes with post-COVID-19 infections. This review also highlights the financial burden of widespread ECG screening, but reinforces the importance of ECG screening in preventing sudden cardiac death (SCD) through comprehensive cardiac evaluations.

Conclusion: This review emphasizes the complexity of ECG interpretation in athletes, highlighting sport-specific, gender-based, and age-related variations. The persistent high false-positive rates underscore the need for refined, sport-specific ECG guidelines. Recent recognition of sports medicine as a primary specialty within the European Union (EU) reinforces the importance of comprehensive physician training. Integrating artificial intelligence (AI) technology into ECG screening can enhance diagnostic accuracy, reduce costs, and facilitate large-scale implementation. Meanwhile, collaborative efforts among clinicians, researchers, and policymakers are essential to developing cost-effective and standardized ECG screening protocols, ensuring improved athlete care, and advancing the field of sports cardiology.