Interpretation and Consequences of Repolarisation Changes in Athletes

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1 Interpretation and Consequences of Repolarisation Changes in Athletes Professor Sanjay Sharma Disclosures: None

2 Athlete s ECG Vagotonia Sinus bradycardia Sinus arrhythmia First degree AVB Repolarisation anomalies Increased chamber size Left ventricular hypertrophy Incomplete RBBB Left atrial enlargement Right atrial enlargement

3 Comparison of ECG Change in Athletes and Sedentary Controls Athletes Controls (%) (%) Sinus bradycardia Repolarisation abnormalities Sinus arrhythmia 52 9 Voltage criteria for LVH Atrial enlargement Incomplete RBBB First degree AV block 5 0

4 Comparison of ECG Change in Athletes and Sedentary Controls Athletes Controls (%) (%) Sinus bradycardia Repolarisation abnormalities Sinus arrhythmia 52 9 Voltage criteria for LVH Atrial enlargement Incomplete RBBB First degree AV block 5 0

5 Repolarisation Changes in Athletes J-point elevation ST-segment elevation Tall T waves ERP COMMON T wave inversions Prolonged QT UNCOMMON Brugada ECG Pattern

6 Athlete s ECG: Early Repolarisation

7 Repolarisation Changes in Athletes J-point elevation ST-segment elevation Tall T waves ERP COMMON T wave inversions Prolonged QT RARE Brugada ECG Pattern

8 LQT1 LQT2 LQT3 or Brugada

9 Causes of SCD in Sport 14% 9% 4% 1% 37% Congenital + Anatomic Cardiomyopathies Arrhythmias Infectious Degenerative Undetermined 35% Acquired "Normal heart" Normal heart in 1-25%

10 Interpretation of Repolarisation Anomalies in Athletes PATHOLOGY Harbingers for fatal arrhythmias PHYSIOLOGY Increased vagal tone Slow heart rates Manifestation of Athlete s Heart

11 Interpretation of Repolarisation Anomalies in Athletes

12 Early Repolarisation

13

14 Athlete s ECG: Early Repolarisation

15 EARLY REPOLARISATION PATTERN 2-6% in general population ERP in the inferior or lateral leads identified in 31% of cases with aborted idiopathic VF (Haisuguerre NEJM 2008) J-point elevation > 0.2 mv in the inferior leads increased risk almost 3-fold (Tikannen NEJM 2009) Deaths occurred in those with horizontal or depressed ST segments

16 879 athletes from 20 different sporting disciplines Students Mean age 18.4 yrs old 64% male. 10% black Early repolarisaton defined a J-point elevation of at least 0.1 mv in at least 2 leads within a given anatomical territory FU 21 ±13 months (7-50)

17 Prevalence and Distribution of Non-Anterior ERP Inferior ER pattern accounted for 14.9% of all non anterior ER

18 Noseworthy et al Circulation Arrhythm Electrophysiol 2011; 4: DISCRETE J DISCRETE NOTCHED J SLURRED J NOTCHED J LATERAL (%) INFERIOR (%) ASCENDING ST HORIZONTAL J-POINT > 0.2 LATERAL (%) INFERIOR (%)

19 Noseworthy et al Circulation Arrhythm Electrophysiol 2011; 4: DISCRETE J DISCRETE NOTCHED J SLURRED J NOTCHED J LATERAL (%) INFERIOR (%) ASCENDING ST HORIZONTAL J-POINT > 0.2 LATERAL (%) INFERIOR (%)

20 Noseworthy et al Circulation Arrhythm Electrophysiol 2011; 4: DISCRETE J DISCRETE NOTCHED J SLURRED J NOTCHED J LATERAL (%) INFERIOR (%) ASCENDING ST HORIZONTAL J-POINT > 0.2 LATERAL (%) INFERIOR (%)

21 Associations with ERP Variable Odds ratio Male vs Female 2.21 ( ) HR per 10bpm decrease 1.54 ( ) Sokolow-Lyon index per mv 2.08 ( ) Black vs non black 5.84 ( ) ( ) for inferior ER

22 Prevalence and Distribution of Non-Anterior ERP V4 V5 40% V6

23 Changes in ER Prevalence with Training

24 T-Wave Inversion

25 Hypertrophic Cardiomyopathy

26 Arrhythmogenic Right Ventricular Cardiomyopathy

27 Prevalence of T-Wave Inversion in Caucasian Athletes Author Year Cohort N Prevalence (%) Sharma Pelliccia ± Pelliccia , (Median 17) Corrado (Mean 15.4)

28 Long-term follow-up of athletes with abnormal ECG (Pelliccia et al. New Engl J Med 2008; 358: ) Study group 81 No symptoms, no CV disease 70 6 Other CV disease HT 3, CAD 1, myocarditis 1, SVT 1) 5 Cardiomyopathies (HCM3; ARVC1; DCM1) 1 cardiac arrest 1 sudden death

29 Juvenile ECG Pattern (T Wave Inversions in Leads V1-V4) in Caucasian Athletes Age < 14 years % Age 14 years 1.4% Age > % beyond V2

30

31 ECG Comparison in Black versus Caucasian Athletes Parameter Black athletes White athletes p N = 911 N = 1819 LVH (%) < LA Enlargement < RA Enlargement < ST elevation (%) < T inversions (%) 23 4 <0.001 Deep T inversions (%) 12 1 <0.001

32 ECG of a 24 Year old Black Soccer Player

33 Distribution of T-Wave Inversion in Black and Caucasian Athletes , % 6 Black athletes 6 White Athletes 4, ,9 1,6 0,3 V1-V4 II, III, avf V5,V6

34 Anterior Precordial ECG Changes in black athletes V1 V2 V3

35 ECG During and After Detraining During peak season Off season

36 ECG Changes in a Black Football Player 14-year follow up

37 16-Year old Professional Soccer Player

38 ECG During and After Detraining During peak season Off season

39 Distribution of T-Wave Inversion in Adolescent Black Athletes (black bars) and Sedentary Controls (grey bars) 0.8% 0.2%

40 Interpretation of T-Wave Inversion Long standing endurance athlete Black athletes Cardiomyopathy Juvenile EKG pattern T-Wave Inversion Anabolic drug abuse

41 Prolonged QT Interval

42 LONG QT INTERVAL DEFECTIVE ION CHANNEL PREDILECTION TO POLYMORPHIC VT/VF

43 Triggers for Sudden Cardiac Death in Long QT Syndrome Loud stimuli Intense emotion Fear Swimming ADRENERGIC SURGE Performance enhancing drugs

44 Long QT Syndrome - Measurement QTc = QT/ RR ABNORMAL (ESC) QTc > 440 in males QTc > 460 in females

45 Problems with QT Measurements in Athletes Slow HR Sinus arrhythmia Slightly wide QRS complexes T-U complexes Prevalence of Long QT in general population 1 in 2000 Prevalence of Long QT in athletes is 1 in 125 to 1 in 250

46 Long QT Syndrome - Measurement QTc = QT/ RR ABNORMAL (ESC) QTc > 440 in males QTc > 460 in females ABNORMAL (AHA) QTc > 470 in males QTc > 480 in females

47 Diagnosis of Long QT Syndrome Diagnosis based on a long QTc in the context of at least 1 of the following: 1. Unheralded Syncope 2. Torsades de pointes 3. Identification of a long QTc in first degree relatives 4. Family history of SADS

48 SCHWARTZ SCORE FOR DIAGNOSIS OF LQTS Finding Score Electrocardiographic Corrected QTc interval (ms) (in males) 1 Scoring Torsades de pointes 2 T-wave alternans 1 1 low probability Notched T waves in 3 leads 1 Low heart rate for age intermediate Clinical history Syncope 4 high probability With stress 2 Without stress 1 Congenital deafness 0.5 Family history Family members with definite LQTS 1 Unexplained SCD in first degree relatives 0.5

49

50 SCHWARTZ SCORE FOR DIAGNOSIS OF LQTS Finding Score Electrocardiographic Corrected QTc interval (ms) (in males) 1 Scoring Torsades de pointes 2 T-wave alternans 1 1 low probability Notched T waves in 3 leads 1 Low heart rate for age intermediate Clinical history Syncope 4 high probability With stress 2 Without stress 1 Congenital deafness 0.5 Family history Family members with definite LQTS 1 Unexplained SCD in first degree relatives 0.5

51 0.4% athletes had Long QT. Athletes with QTc 500 exhibited other features of the syndrome.

52 Brugada Syndrome and Sport Bradycardia Hyperpyrexia

53 Athlete s ECG versus Brugada Pattern Brugada type A ST J ST 80 STJ: ST 80 < 1 Athlete s Heart STJ: ST 80 > 1

54 Anterior Precordial ECG Changes in Black athletes V1 V2 V3

55 Investigation of Type 2 and 3 Brugada Pattern?Symptoms?Family history?type A pattern in V1 and V2 in 2 nd inter-costal leads NO Leave well alone YES Provocation test

56 Repolarisation Anomalies in Athletes NORMAL J-point elevation/st-segment elevation Tall T waves T-wave inversion in V1-V4 in black athletes T-wave inversion in V1-V4 in athletes 14 years old

57 Repolarisation Anomalies in Athletes POSSIBLY ABNORMAL IN SOME ATHLETES ERP > 0.2 mv in the inferior leads with horizontal or down-sloping ST segment. Brugada ECG pattern (type 2 and 3) Prolonged QT interval msec T wave inversion in inferior and lateral leads in black athletes

58 Repolarisation Anomalies in Athletes ABNORMAL IN MOST ATHLETES ST-segment depression T wave inversion beyond V2 in adult Caucasian athletes Brugada type 1 ECG pattern Short QT interval QTc 500 msec

59 Conclusions Increased vagal tone and slow heart rates may occasional cause overlap disorders implicated in SCD Repolarisation changes should be interpreted in the context of the demographics of the athlete An isolated ECG anomaly should not be should to make a diagnosis in an athlete in most cases Apply only to athletes aged years old

60 Interpretation and Consequences of Repolarisation Changes in Athletes Professor Sanjay Sharma Disclosures: None

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