The frontier between normal and abnormal electrocardiogram in athletes

Transcription

1 The frontier between normal and abnormal electrocardiogram in athletes ESC Congress 2011 Paris F. Carré University Rennes 1-Pontchaillou Hospital Inserm U642, Rennes - F-35000

2 Cardiovascular preparticipation screening before competitive sport Competitive sport between y.o. ESC, FIFA, IOC recommendations Familial and personal history and Physical examination and 12 lead-ecg

3 CV- PPS History, physical exam 12 leads-ecg History and/or Physical exam ABNORMALITY + ECG «normal» ECG «abnormal» Adapted CV exams Temporary/definitive disqualification for intensive sport

4 CV- PPS History, physical exam 12 leads-ecg History Physical exam ABNORMALITY + History Physical exam NO ABNORMALITY ECG «normal» ECG «abnormal» ECG «normal» ECG «abnormal» Adapted CV exams Temporary disqualification for intensive sport CV clearance CV exams Temporary disqualification for intensive sport

5 «Abnormal» ECG in athlete, first classification Corrado et al, Eur Heart J 2005;26: Baggish AL et al, Ann Intern Med 2010;152: > 16 % of abnormal ECG (Spe 91% and Spe 83%)

6 How to improve this limit? Analysis by general physicians Cardiologist advice or not CV PPS aims detection of cardiac disease - with an increased SD risk - with a risk of worsening with intensive sport High level of training can modify ECG patterns - Cardiac hypertrophy - Autonomic nervous system alterations - Intrinsic cellular adaptations Athlete s heart? Myocardial disease HCM DCM ARVC Myocarditis

7 What is a normal ECG in an athlete? Abnormal ECG

8 What is a normal ECG in an athlete? Abnormal ECG Gademan MG et al Eur J Cardiovasc Prev Rehabil Mandic S et al.phys Sportsmed. 2010;38:

9 Athlete s ECG: the level of training Parameters Sedentary Low level training 4-6 h/week High level training > 6 h/week Normal ECG 95% 88% 65% «Abnormal» ECG <5% 12% 45% Bradycardia < 50 bpm <0.5% 7% 18% Incomplete RBB, ERP, Firsty degree AVB < 5% 7% 34% Isolated LVH <0,5% 1% 40% Negative T waves 2% 2.3% 2.7% Pelliccia et al Circulation 2000 Pellicica A et al Eur Heart J 2007 Personal data

10 Pelliccia et al Circulation 2000 Athlete s ECG : sport s effect

11 Athlete s ECG, training s effect Barbier J et al Herz 2006

12 Athlete s ECG: gender effect Elite athletes training > 8h/w Amateur athletes training < 6h/w Pelliccia A et al Circulation 2000 Pelliccia A et al Eur Heart J 2007

13 % de sportifs % athletes Athlete s ECG, gender effect 50 Women (405) % Men (820) < < < < < Heart rate Fréquence cardiaque (batt.min -1 ) Incomplete RBB

14 ECG variants in athletes, new classification Corrado D et al. Eur Heart J 2010 Weiner RB et al. Heart 2011 < 10 % of abnormal ECG athletes (Se 91% and Spe 90%)

15 CV- PPS History, physical exam 12 leads-ecg History Physical exam ABNORMALITY + History Physical exam NO ABNORMALITY ECG «normal» ECG «abnormal» ECG «normal» ECG «Common changes» ECG «Uncommon changes» Adapted CV exams Temporary disqualification for intensive sport CV clearance Athlete s heart CV clearance CV exams Temporary disqualification for intensive sport

16 Is that all uncommon ECG changes have the same weight prognosis? RBBB Axis deviation LA enlargment RV hypertrophy ERS Ventricular preexcitation Epsilon waves Complete LBBB Pathological Q waves ST-segment depression Arrhythmias LQT,SQT T wave -inversion Same CV examinations? Same follow-up?

17 Uncommon changes with good prognosis CRBBB QRS Axis deviation LA enlargment RV hypertrophy Kim JH, et al. Am J Cardiol. 2011;107: Papdakis M and Sharma S Br J Sports Med 2009;43:663-8 Sharma S et al Heart 2011

18 Arrhythmias in athletes? Uncommon change in athlete Ventricular arrhythmias More than one SVPB Asymptomatic cyclist 22 y.o. Further CV examination needed Biffi A, et al. J Am Coll Cardiol 2004; 44: Heidbuchel H, Eur Heart J 2003; 24: Heidbuchel et al Eur J Cardiovasc Prev Rehabil 13: Heidbuchel H et al Eur J Cardiovasc Prev Rehabil 13:475 84

19 QTc duration in athletes, which limits? 5130 athletes 3514 males 1676females Kervio G et al Europrevent 2009 Limits Males Females ESC (> ) 129 (3.7%) 31 (1.9%) Bethesda ( ) 16 (0.46%) 9 (0.54%) Basavarajaiah (>500) 2 (0.06%) 1 (0.06%)

20 Early repolarisation syndrom % athletes, black++ Increased risk of SD ++ in inferior and lateral leads Notching or slurring ERS 20-30% in athletes; male, black, LVH, bradycardia In asymptomatic athlete no further CV exams needed, full clearance for intensive sport Tikkanen JT et al Circulation 2011;123: Noseworthy PA et al Circ Arrhythm Electrophysiol 2011; 4: Cappato R et al Circ Arrhythm Electrophysiol 2010;3: Junttila MJ J Interv Card electrophysiol 2011;31:33-8 Haïssaguerre M, et al. N Engl J Med 2008;358:

21 T waves abnormalities Brugada like early repolarisation Corrado et al Eur Heart J 2010 Brugada Athletes Age effect Ethnicity effect

22 Athlete s ECG, age effect Papadakis M et al. Eur Heart J Athletes (1414 M, 96 % caucasians) 400 Controls (330 M 96% caucasians) T negative A 4% C 3% T positive A 96% C 97% V1-V4 A 2.5% C 3 % D2,D3,VF ± D1, VL A 1.5% C 0% 16 ans A 0.1% C 0% > V2 A 0.8% C 0.5% < 16 ans A 0.7% C 0.5% V1-V2 A 1.7% C 2.5% Athletes 16 y.o. inverted T waves 4 % V1-V2 ++ If > V2 Eliminate ARVC

23 Ethnicity

24 ECG in sedentary people, ethnicity effects Controls African Caucasian Japanese North African West Asian n=127 n=110 n=50 n=67 n=135 Distinctly ECG abnormalities 4% 5% 0% 6% 5% Isolated LVH 2% 3% 0% 4% 3% J point upward/ Diphasic T waves 8% ** 0% 0% 2% 0% Inverted T waves 0% 0% 0% 0% 0% Wilson M et al. Br J Sports Med Kervio G et al Europrevent 2011 Unpublished personal data

25 ECG in athletes, ethnicity effects Soccer players African Caucasian Japanese North African West-Asian n=96 n=118 n=68 n=49 n=400 Distinctly ECG abnormalities 34%** 8% 16% 6% 7% Isolated LVH 10%** 4% 9% 2% 4% J point upward/ Diphasic T waves 17%*** 2% 6% 4% 3,5% Inverted T waves 6%*** 0% 0% 0% 1% Wilson M et al. Br J Sports Med Kervio G et al Europrevent 2011 Unpublished personal data

26 ECG ethnicity effects in women athletes Deep inverted T waves 2 % 0 % Rawlins J et al Circulation 2010;121:

27 J point upward / Diphasic T waves V1-V4 Afro-carribean athletes 15-25% Exercise test, Echocardiography Good prognosis No specific follow-up Rawlins J et al Circulation 2010;121: Papadakis M et al. Eur Heart J 2011

28 Deep inverted T waves Lateral leads ++ Afro-Carribean athletes ++ (5-10%) Exercise test, echocardiography, Holter,C-MRI Even if normal annual follow up Pelliccia A et al N Engl J Med 2008;358: Magalski A et al J Am Coll Cardiol 2008;51: Rawlins J et al Circulation 2010;121: Papadakis M et al. Eur Heart J 2011

29 CV- PPS History,physical exam, NO ABNORMALITY 12 leads-ecg Normal Training related changes Training unrelated changes Sinus bradycardia AVB 1 IRBBB Isolated LVH Early repolarisation syndrom CRBB Axis deviation Isolated LA enlargment Isolated RV hypertrophy Arrhythmias Preexcitation Wave LQT-SQT CLBBB Epsilon wave ST segment-depression Pathological Q wave Negative T wave Brugada like ERP (?) CV clearance for intensive sport Adapted CV exams Temporary/definitive disqualification for intensive sport