Sport-specific electrocardiographic patterns in Moroccan university athletes: a Seattle criteria-based cross-sectional study
DOI:
https://doi.org/10.47197/retos.v75.118025Keywords:
athlete’s heart, electrocardiography, sport type, sports cardiology, Seattle criteriaAbstract
Background: Exercise-induced cardiac remodelling results in electrocardiographic alterations that vary by sport and ethnicity. International screening criteria, derived primarily from Caucasian populations, may inadequately capture physiological variations in North African athletes.
Aim: To establish electrocardiographic profiles of Moroccan university athletes using the Seattle International Criteria and to analyse sport-specific variations.
Methods: This cross-sectional study enrolled 149 university athletes (79 male, 70 female, aged 18-25 years) from Hassan I University in Morocco, classified into endurance, mixed/team and strength/power sports. Standardised 12-lead electrocardiography was interpreted independently by two specialists. ANOVA and chi-square tests were used for statistical analysis, and effect sizes were reported. Results: Significant differences in heart rate between sports emerged (p < .001, η² = .124): endurance athletes showed lower rates (58.4 ± 11.2 bpm) compared to mixed/team athletes (65.1 ± 11.8 bpm) and strength/power athletes (68.9 ± 12.5 bpm). The prevalence of sinus bradycardia was higher in endurance athletes (47.5% vs. 27.0% in mixed/team and 25.0% in strength/power; p = .018). Training-related findings were frequent (34.9% sinus bradycardia overall), borderline findings occurred in 5.4-8.1% and abnormal findings were minimal (6.0%).
Conclusions: Moroccan athletes demonstrate sport-specific electrocardiographic adaptations with lower abnormality rates than those reported in sub-Saharan African populations, suggesting North African heterogeneity. The findings challenge assumptions about continental generalisations and support region-specific regulatory frameworks rather than universally applicable criteria, especially among endurance athletes who show pronounced bradycardic adaptations.
References
Adea, J.-E. B., Leonor, R. M. L., Lu, C.-H., Lin, L.-C., Wu, M., Lee, K.-T., Lin, Y.-S., Chang, S.-H., Hung, K.-C., Lin, F.-C., Hsieh, I.-C., Chu, P.-H., Wen, M.-S., Wu, V. C.-C., & Wang, C.-L. (2020). Sport disciplines and cardiac remodeling in elite university athletes competing in 2017 Taipei Summer Univer-siade. Medicine, 99(45), e23144. https://doi.org/10.1097/MD.0000000000023144
Basu, J., & Malhotra, A. (2018). Interpreting the Athlete’s ECG: Current State and Future Perspectives. Current Treatment Options in Cardiovascular Medicine, 20(12), 104. https://doi.org/10.1007/s11936-018-0693-0
Brouki, Y., El Machrouh, Y., Khali, C., Barkaoui, M., Eloirdi, A., Zahi, B., & Chokri, A. (2025). Sex differ-ences and physical activity associations with electrocardiographic patterns in amateur athletes: A cross-sectional study. Retos, 71, 555–565. https://doi.org/10.47197/retos.v71.117255
Caramoci, A., Smaranda, A. M., Drăgoiu, T. S., & Bădărău, I. A. (2025). ECG Screening in Athletes: A Sys-tematic Review of Sport, Age, and Gender Variations. Reviews in Cardiovascular Medicine, 26(5), 38209. https://doi.org/10.31083/RCM38209
Celeski, M., Segreti, A., Piscione, M., Monticelli, L. M., Di Gioia, G., Fossati, C., Ussia, G. P., Pigozzi, F., & Grigioni, F. (2025). The current paradigm of cardiac troponin increase among athletes. Monaldi Archives for Chest Disease, 95(2). https://doi.org/10.4081/monaldi.2024.2878
Churchill, T. W., Petek, B. J., Wasfy, M. M., Guseh, J. S., Weiner, R. B., Singh, T. K., Schmied, C., O’Malley, H., Chiampas, G., & Baggish, A. L. (2021). Cardiac Structure and Function in Elite Female and Male Soccer Players. JAMA Cardiology, 6(3), 316. https://doi.org/10.1001/jamacardio.2020.6088
Dalen, H., Letnes, J. M., Hoydal, M. A., & Wisløff, U. (2024). Diastolic function and dysfunction in athletes. European Heart Journal - Cardiovascular Imaging, 25(11), 1537–1545. https://doi.org/10.1093/ehjci/jeae155
D’Ascenzi, F., Cavigli, L., Marchese, A., Taddeucci, S., Cappelli, E., Roselli, A., Bastone, G., Lemme, E., Ser-doz, A., Maestrini, V., Squeo, M. R., & Pelliccia, A. (2024). Electrical and structural remodelling in female athlete’s heart: A comparative study in women vs men athletes and controls. Interna-tional Journal of Cardiology, 400, 131808. https://doi.org/10.1016/j.ijcard.2024.131808
Di Gioia, G., Ferrera, A., Ortolina, D., Pelliccia, A., & Squeo, M. R. (2026). Myocardial work index as a marker for physiologic cardiac remodeling in elite endurance athletes. International Journal of Cardiology, 442, 133863. https://doi.org/10.1016/j.ijcard.2025.133863
Di Gioia, G., Ferrera, A., Vespasiano, F., Maestrini, V., Monosilio, S., Lemme, E., Serdoz, A., Mango, F., Cas-ciani, E., Pelliccia, A., & Squeo, M. R. (2024). Insight on Exercise-Induced Heart Remodeling in Different Track and Field Disciplines. Journal of Clinical Medicine, 13(20), 6027. https://doi.org/10.3390/jcm13206027
Drezner, J. A., Sharma, S., Baggish, A., Papadakis, M., Wilson, M. G., Prutkin, J. M., Gerche, A. L., Ackerman, M. J., Borjesson, M., Salerno, J. C., Asif, I. M., Owens, D. S., Chung, E. H., Emery, M. S., Froelicher, V. F., Heidbuchel, H., Adamuz, C., Asplund, C. A., Cohen, G., … Corrado, D. (2017). International cri-teria for electrocardiographic interpretation in athletes: Consensus statement. British Journal of Sports Medicine, 51(9), 704–731. https://doi.org/10.1136/bjsports-2016-097331
D’Souza, A., Bucchi, A., Johnsen, A. B., Logantha, S. J. R. J., Monfredi, O., Yanni, J., Prehar, S., Hart, G., Cart-wright, E., Wisloff, U., Dobryznski, H., DiFrancesco, D., Morris, G. M., & Boyett, M. R. (2014). Ex-ercise training reduces resting heart rate via downregulation of the funny channel HCN4. Nature Communications, 5(1), 3775. https://doi.org/10.1038/ncomms4775
Egger, F., Serner, A., Wilke, C. F., Grimm, K., Massey, A., Meyer, T., & Baggish, A. L. (2025). Global cardiac screening practices among youth and adult football players: The FIFA cardiac screening survey. British Journal of Sports Medicine, 59(20), 1410–1417. https://doi.org/10.1136/bjsports-2025-109949
El Fahime, E., Kartti, S., Chemao-Elfihri, M. W., Festali, R., Hakmi, M., Ibrahimi, A., Boutayeb, S., & Belyamani, L. (2025). Moroccan genome project: Genomic insight into a North African popula-tion. Communications Biology, 8(1), 584. https://doi.org/10.1038/s42003-025-08020-z
El Ouali, E. M., Kartibou, J., Del Coso, J., El Makhzen, B., Bouguenouch, L., El Akbir, R., El Haboussi, A., Akhouayri, O., Ibrahimi, A., Mesfioui, A., & Zouhal, H. (2025). Exploring the Association Between CD36 rs1761667 Polymorphism and Susceptibility to Non-Contact Tissue Injuries in Moroccan Elite Cyclists and Field Hockey Players: A Pilot Study. Genes, 16(6), 651. https://doi.org/10.3390/genes16060651
Forså, M. I., Bjerring, A. W., Haugaa, K. H., Smedsrud, M. K., Sarvari, S. I., Landgraff, H. W., Hallén, J., & Edvardsen, T. (2023). Young athlete’s growing heart: Sex differences in cardiac adaptation to exercise training during adolescence. Open Heart, 10(1), e002155. https://doi.org/10.1136/openhrt-2022-002155
Hallak, Y., Battistin, U., & Al-Masaeed, A. M. (2020). Cardiac Screening To Mitigate The Risk Of Sudden Cardiac Death In Middle Eastern And African Competitive Athletes. A Systematic Review. Jour-nal of the Saudi Heart Association, 32(2), 174–185. https://doi.org/10.37616/2212-5043.1047
Kim, J. H., Baggish, A. L., Levine, B. D., Ackerman, M. J., Day, S. M., Dineen, E. H., Guseh, J. S., La Gerche, A., Lampert, R., Martinez, M. W., Papadakis, M., Phelan, D. M., Shafer, K. M., & on behalf of the Amer-ican Heart Association Leadership Committee of the Council on Clinical Cardiology; Council on Basic Cardiovascular Sciences; Council on Cardiovascular and Stroke Nursing; Council on Cardi-ovascular Surgery and Anesthesia; Council on Peripheral Vascular Disease; and American Col-lege of Cardiology. (2025). Clinical Considerations for Competitive Sports Participation for Ath-letes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart As-sociation and American College of Cardiology. Circulation, 151(11). https://doi.org/10.1161/CIR.0000000000001297
Kramer, T., Ventovuori, V., Heinonen, A., Parkkari, J., Korhonen, M. T., Rovio, A., Hoenemann, J.-N., Möstl, S., Sies, W., Kaiser-Stolz, C., Chilibeck, P., Tanaka, H., Kramer, M., Rittweger, J., & Hautala, A. J. (2024). Prevalence of electrocardiographic markers associated with myocardial fibrosis in masters athletes: A cohort study. BMJ Open Sport & Exercise Medicine, 10(3), e001988. https://doi.org/10.1136/bmjsem-2024-001988
Lander, B. S., Duffy, E. Y., Hennessey, J. A., Tolani, S., Patel, N., Bohnen, M. S., Hsu, J. J., Danielian, A., Shah, A. B., Goolsby, M., Martinez, M. W., Phelan, D., & Engel, D. J. (2024). Electrocardiographic Find-ings in Female Professional Basketball Athletes. JAMA Cardiology, 9(5), 475. https://doi.org/10.1001/jamacardio.2024.0207
Maillot, N., Guenancia, C., Yameogo, N. V., Gudjoncik, A., Garnier, F., Lorgis, L., Chagué, F., & Cottin, Y. (2018). Impact of the dynamic and static component of the sport practised for electrocardio-gram analysis in screening athletes. Scandinavian Journal of Medicine & Science in Sports, 28(2), 575–584. https://doi.org/10.1111/sms.12949
Małek, Ł. A., Dotka, M., Brzezińska, K., Pyndryk, P., Materkowski, M., & Wiecha, S. (2025). Electrocardi-ographic Changes in Juvenile Athletes in Relation to Sex, Age, and Sport Category. Pediatric Car-diology. https://doi.org/10.1007/s00246-025-03945-y
Mesirca, P., Nakao, S., Nissen, S. D., Forte, G., Anderson, C., Trussell, T., Li, J., Cox, C., Zi, M., Logantha, S., Yaar, S., Cartensen, H., Bidaud, I., Stuart, L., Soattin, L., Morris, G. M., Da Costa Martins, P. A., Cart-wright, E. J., Oceandy, D., … D’Souza, A. (2021). Intrinsic Electrical Remodeling Underlies Atrio-ventricular Block in Athletes. Circulation Research, 129(1). https://doi.org/10.1161/CIRCRESAHA.119.316386
Moulson, N., Petek, B. J., Drezner, J. A., Harmon, K. G., Kliethermes, S. A., Patel, M. R., Baggish, A. L., Asif, I. M., Borchers, J., Edenfield, K. M., Emery, M. S., Goerl, K., Hainline, B., Kim, J. H., Kraus, W. E., Lam-pert, R., Leiszler, M., Levine, B. D., Martinez, M. W., … Zorn, S. T. (2021). SARS-CoV-2 Cardiac In-volvement in Young Competitive Athletes. Circulation, 144(4), 256–266. https://doi.org/10.1161/CIRCULATIONAHA.121.054824
Oxborough, D., George, K., Cooper, R., Bhatia, R., Ramcharan, T., Zaidi, A., Gati, S., Prakash, K., Rakhit, D., Robinson, S., Stuart, G., Forster, J., Ackrill, M., Augustine, D., Malhotra, A., Papadakis, M., Castellet-ti, S., Pettemerides, V., Ring, L., … Sharma, S. (2025). Echocardiography in the cardiac assess-ment of young athletes: A 2025 guideline from the British Society of Echocardiography (en-dorsed by Cardiac Risk in the Young). Echo Research & Practice, 12(1), 7. https://doi.org/10.1186/s44156-025-00069-0
Ozo, U., & Sharma, S. (2020). The Impact of Ethnicity on Cardiac Adaptation. European Cardiology Re-view, 15, e61. https://doi.org/10.15420/ecr.2020.01
Palermi, S., Cavarretta, E., D’Ascenzi, F., Castelletti, S., Ricci, F., Vecchiato, M., Serio, A., Cavigli, L., Bos-sone, E., Limongelli, G., Biffi, A., Monda, E., La Gerche, A., Baggish, A., & D’Andrea, A. (2023). Ath-lete’s Heart: A Cardiovascular Step-By-Step Multimodality Approach. Reviews in Cardiovascular Medicine, 24(5), 151. https://doi.org/10.31083/j.rcm2405151
Pamart, N., Drigny, J., Azambourg, H., Remilly, M., Lahjaily, K., Rocamora, A., Tournoux, F., Saloux, E., Reboursière, E., Gauthier, A., & Hodzic, A. (2025). Association between muscle strength gains and biventricular cardiac remodeling in response to high-intensity resistance training in healthy untrained males: A longitudinal study. BMC Sports Science, Medicine and Rehabilitation, 17(1), 116. https://doi.org/10.1186/s13102-025-01165-8
Pambo, P., & Scharhag, J. (2021). Electrocardiographic and Echocardiographic Findings in Black Ath-letes: A General Review. Clinical Journal of Sport Medicine, 31(3), 321–329. https://doi.org/10.1097/JSM.0000000000000754
Pelliccia, A., Drezner, J. A., Zorzi, A., & Corrado, D. (2024). Prevalence and clinical significance of low QRS voltages in healthy individuals, athletes, and patients with cardiomyopathy: Implications for sports pre-participation cardiovascular screening. European Journal of Preventive Cardiol-ogy, 31(9), 1106–1114. https://doi.org/10.1093/eurjpc/zwae027
Riding, N. R., Sharma, S., McClean, G., Adamuz, C., Watt, V., & Wilson, M. G. (2019). Impact of geograph-ical origin upon the electrical and structural manifestations of the black athlete’s heart. Europe-an Heart Journal, 40(1), 50–58. https://doi.org/10.1093/eurheartj/ehy521
Rojas-Valencia, J. T., Higuera-Dagovett, E., Vega Llamas, R., Prieto Mondragón, L. D. P., Buitrago Espitia, J. E., & Rodríguez Buitrago, J. A. (2024). Electrocardiographic findings in a group of physically active young adults who reside at 2,600 meters above the sea level: An exploratory study. Retos, 59, 577–583. https://doi.org/10.47197/retos.v59.103145
Saavedra, J. M., Escalante, Y., & Rodríguez, F. A. (2010). A Multivariate Analysis of Performance in Young Swimmers. Pediatric Exercise Science, 22(1), 135–151. https://doi.org/10.1123/pes.22.1.135
Segreti, A., Celeski, M., Guerra, E., Crispino, S. P., Vespasiano, F., Buzzelli, L., Fossati, C., Papalia, R., Pigoz-zi, F., & Grigioni, F. (2024). Effects of Environmental Conditions on Athlete’s Cardiovascular System. Journal of Clinical Medicine, 13(16), 4961. https://doi.org/10.3390/jcm13164961
Sharma, S., Drezner, J. A., Baggish, A., Papadakis, M., Wilson, M. G., Prutkin, J. M., La Gerche, A., Acker-man, M. J., Borjesson, M., Salerno, J. C., Asif, I. M., Owens, D. S., Chung, E. H., Emery, M. S., Froeli-cher, V. F., Heidbuchel, H., Adamuz, C., Asplund, C. A., Cohen, G., … Corrado, D. (2017). Interna-tional Recommendations for Electrocardiographic Interpretation in Athletes. Journal of the American College of Cardiology, 69(8), 1057–1075. https://doi.org/10.1016/j.jacc.2017.01.015
Sheikh, N., Papadakis, M., Wilson, M., Malhotra, A., Adamuz, C., Homfray, T., Monserrat, L., Behr, E. R., & Sharma, S. (2018). Diagnostic Yield of Genetic Testing in Young Athletes With T-Wave Inver-sion. Circulation, 138(12), 1184–1194. https://doi.org/10.1161/CIRCULATIONAHA.118.034208
Tardo, D. T., & Papadakis, M. (2025). Are the Cardiovascular Benefits and Potential Risks of Physical Activity and Exercise Dependent on Race, Ethnicity, or Sex? Canadian Journal of Cardiology, 41(3), 456–469. https://doi.org/10.1016/j.cjca.2024.11.013
Wang, L., Yeo, T. J., Tan, B., Destrube, B., Tong, K. L., Tan, S. Y., Chan, G., Huang, Z., Tan, F., Wang, Y. C., Lee, J.-Y., Fung, E., Mak, G. Y. K., So, R., Wanlapakorn, C., Ambari, A. M., Cuenza, L., Koh, C. H., & Tan, J. W. C. (2021). Asian Pacific Society of Cardiology Consensus Recommendations for Pre-participation Screening in Young Competitive Athletes. European Cardiology Review, 16, e44. https://doi.org/10.15420/ecr.2021.26
Zimmermann, P., Moser, O., Edelmann, F., Schöffl, V., Eckstein, M. L., & Braun, M. (2022). Electrical and Structural Adaption of Athlete’s Heart and the Impact on Training and Recovery Management in Professional Basketball Players: A Retrospective Observational Study. Frontiers in Physiology, 13, 739753. https://doi.org/10.3389/fphys.2022.739753
Zorzi, A., Vio, R., Bettella, N., & Corrado, D. (2020). Criteria for interpretation of the athlete’s ECG: A crit-ical appraisal. Pacing and Clinical Electrophysiology, 43(8), 882–890. https://doi.org/10.1111/pace.14001
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