{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T18:50:29Z","timestamp":1792003829410,"version":"4.4.0"},"reference-count":24,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T00:00:00Z","timestamp":1777420800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCDD"],"abstract":"<jats:p>Background: Artificial intelligence (AI) has shown promise in the interpretation of electrocardiograms (ECGs) using signal-based deep learning models. In parallel, large language models (LLMs) have gained increasing visibility in clinical practice, including exploratory applications in ECG analysis. Whether a general-purpose LLM can meaningfully discriminate cardiovascular disease from athlete ECGs during PPS remains unknown. We aimed to evaluate the diagnostic performance of a general-purpose LLM for this task. Methods: In this multicentre diagnostic accuracy study, we evaluated a commercially available LLM (ChatGPT, version 5) in 2950 competitive athletes undergoing PPS. All athletes underwent resting 12-lead ECG, with second- and third-line investigations performed when clinically indicated. The reference outcome was confirmed cardiovascular disease after full diagnostic work-up (n = 450, 15.3%). For each ECG, the LLM generated a numeric score (0\u2013100) representing the inferred likelihood of underlying disease using a standardized prompt and without task-specific fine-tuning. Discriminative performance was assessed using receiver operating characteristic (ROC) analysis. Misclassification patterns were analysed according to International ECG Criteria. Results: GPT-derived scores demonstrated a marked floor effect, with a median value of 0 (IQR 0\u20132) in both diseased and non-diseased athletes and substantial overlap between groups. The area under the ROC curve was 0.52 (95% CI 0.49\u20130.55), indicating performance close to random classification. At the Youden-derived threshold, 79% of athletes with confirmed disease were incorrectly classified as negative. False-negative cases were predominantly characterized by borderline ECG patterns (82%), and a substantial number of red-flag ECG abnormalities were also missed. Conclusions: In this PPS cohort, a general-purpose LLM used in a na\u00efve configuration showed no clinically meaningful ability to discriminate between cardiovascular disease and athlete ECGs. Without task-specific training or domain adaptation, such models should not be used for diagnostic triage in athlete screening.<\/jats:p>","DOI":"10.3390\/jcdd13050191","type":"journal-article","created":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T08:03:47Z","timestamp":1777536227000},"page":"191","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["ChatGPT\u2019s Limitations in Athlete ECG Interpretation: Evidence from a Multicenter Diagnostic Study"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1558-4857","authenticated-orcid":false,"given":"Stefano","family":"Palermi","sequence":"first","affiliation":[{"name":"Department of Medicine and Surgery, UniCamillus Saint Camillus International University of Health Sciences, 00131 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2395-4977","authenticated-orcid":false,"given":"Marco","family":"Vecchiato","sequence":"additional","affiliation":[{"name":"Sports and Exercise Medicine Division, Department of Medicine, University of Padova, 35122 Padova, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tommaso Remo","family":"Iacovone","sequence":"additional","affiliation":[{"name":"Department of Medicine and Surgery, UniCamillus Saint Camillus International University of Health Sciences, 00131 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6311-4270","authenticated-orcid":false,"given":"Matteo","family":"Anselmino","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Cardiovascular and Thoracic Department, Citt\u00e0 della Salute e della Scienza di Torino Hospital, 10126 Turin, Italy"},{"name":"Department of Medical Sciences, University of Turin, 10124 Turin, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9577-2155","authenticated-orcid":false,"given":"Rachele","family":"Adorisio","sequence":"additional","affiliation":[{"name":"Bambino Ges\u00f9 Children\u2019s Hospital, IRCCS, 00165 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alessandro","family":"Biffi","sequence":"additional","affiliation":[{"name":"Med-Ex, Medicine & Exercise, Medical Partner Scuderia Ferrari, 00187 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-6938-0806","authenticated-orcid":false,"given":"Francesco","family":"Borrelli","sequence":"additional","affiliation":[{"name":"Sports Medicine Institute, 10143 Turin, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erica","family":"Brugin","sequence":"additional","affiliation":[{"name":"Sports and Exercise Medicine Division, Department of Medical Specialties, ULSS 3 Serenissima, 30174 Venice, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9888-2395","authenticated-orcid":false,"given":"Nicoletta","family":"Cantarutti","sequence":"additional","affiliation":[{"name":"Bambino Ges\u00f9 Children\u2019s Hospital, IRCCS, 00165 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0221-6000","authenticated-orcid":false,"given":"Elena","family":"Cavarretta","sequence":"additional","affiliation":[{"name":"Bambino Ges\u00f9 Children\u2019s Hospital, IRCCS, 00165 Rome, Italy"},{"name":"Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4315-0282","authenticated-orcid":false,"given":"Mattia","family":"Cominacini","sequence":"additional","affiliation":[{"name":"Department of Engineering for Innovation Medicine, University of Verona, 37100 Verona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4556-5091","authenticated-orcid":false,"given":"Marco","family":"Corsi","sequence":"additional","affiliation":[{"name":"Sports Medicine Center, University of Florence, 50100 Florence, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0947-6836","authenticated-orcid":false,"given":"Flavio","family":"D\u2019Ascenzi","sequence":"additional","affiliation":[{"name":"Sports Cardiology and Rehab Unit, Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vittorio","family":"De Feo","sequence":"additional","affiliation":[{"name":"M.d.S. srl, 65100 Pescara, Italy"},{"name":"University Cardiology Division, SS Annunziata Polyclinic University Hospital, 66100 Chieti, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9158-5440","authenticated-orcid":false,"given":"Giuseppe","family":"Di Gioia","sequence":"additional","affiliation":[{"name":"Institute of Sport Medicine and Science, Italian National Olympic Committee, Largo Piero Gabrielli, 00197 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9004-7587","authenticated-orcid":false,"given":"Gianluigi","family":"Dorelli","sequence":"additional","affiliation":[{"name":"Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, 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Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9475-1507","authenticated-orcid":false,"given":"Andrea","family":"Saglietto","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Cardiovascular and Thoracic Department, Citt\u00e0 della Salute e della Scienza di Torino Hospital, 10126 Turin, Italy"},{"name":"Department of Medical Sciences, University of Turin, 10124 Turin, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,29]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"533","DOI":"10.23736\/S0026-4806.24.09519-3","article-title":"Italian Cardiological Guidelines (COCIS) for Competitive Sport Eligibility in athletes with heart disease: Update 2024","volume":"115","author":"Zeppilli","year":"2024","journal-title":"Minerva 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