Comparative Performance of Wearable ECG Devices for Rhythm Monitoring in Endurance Athletes

Athletes frequently report palpitations during exercise, yet reliable electrocardiographic (ECG) rhythm monitoring during exercise remains a challenge in sports cardiology. This study compared the signal quality and user experience of multiple wearable ECG devices during exercise and prolonged ambulatory monitoring in endurance athletes. Fifteen healthy recreational cyclists underwent a supervised three-hour cycling session followed by seven days of ambulatory monitoring using three wearable ECG devices: a single-lead ECG patch (SLP), single-lead ECG chest-strap (SLCS), and a multi-lead ECG patch (MLP). During exercise, the SLCS achieved the highest percentage of interpretable ECG recordings (100.0% 99.69–100.0), significantly outperforming the SLP (98.1% 92.1–100.0; p = 0.021) and the MLP (77.07% 30.09–97.86; p = 0.009). Over 7 days, the SLP provided the longest total recording time (10,080 ± 0 min), while the SLCS captured the greatest proportion of time during exercise (33 ± 27% vs. <10% for other devices). Patch-based systems were preferred by participants for comfort and sleep but were associated with more frequent skin irritation. The SLCS was perceived as superior for fit during exercise but less comfortable for daily use. The SLCS provides superior signal quality during exercise but is less likely to be worn during periods of rest and daily activities. Patch-based ECG devices are less reliable during exercise but allow continuous 24-hour recording. Wearable ECG device selection should therefore be individualized with SLCS preferred for exercise-associated symptoms and patch-based systems for continuous rhythm monitoring.