Reliability and validity of clinician ECG interpretation for athletes

Background: Electrocardiogram (ECG) with preparticipation evaluation (PPE) for athletes remains controversial in the United States and diagnostic accuracy of clinician ECG interpretation is unclear. This study aimed to assess reliability and validity of clinician ECG interpretation using expert-validated ECGs according to the 2010 European Society of Cardiology (ESC) interpretation criteria.

Methods: This is a blinded, prospective study of diagnostic accuracy of clinician ECG interpretation. Anonymized ECGs were validated for normal and abnormal patterns by blinded expert interpreters according to the ESC interpretation criteria from October 2011 through March 2012. Six pairs of clinician interpreters were recruited from relevant clinical specialties in an academic medical center in March 2012. Each clinician interpreted 85 ECGs according to the ESC interpretation guidelines. Cohen and Fleiss' kappa, sensitivity, and specificity were calculated within specialties and across primary care and cardiology specialty groups.

Results: Experts interpreted 189 ECGs yielding a kappa of 0.63, demonstrating "substantial" inter-rater agreement. A total of 85 validated ECGs, including 26 abnormals, were selected for clinician interpretation. The kappa across cardiology specialists was "substantial" and "moderate" across primary care (0.69 vs 0.52, respectively, P < 0.001). Sensitivity and specificity to detect abnormal patterns were similar between cardiology and primary care groups (sensitivity 93.3% vs 81.3%, respectively, P = 0.31; specificity 88.8% vs 89.8%, respectively, P = 0.91).

Conclusions: Clinician ECG interpretation according to the ESC interpretation criteria appears to demonstrate limited reliability and validity. Before widespread adoption of ECG for PPE of U.S. athletes, further research of training focused on improved reliability and validity of clinician ECG interpretation is warranted.