François Carré Hôpital Pontchaillou -INSERM UMR1099-Université Rennes 1

Transcription

1 Normal electrocardiogram variants in Athletes François Carré Hôpital Pontchaillou -INSERM UMR1099-Université Rennes 1

2 Disclosures No disclosure of interest concerning this lecture

3 The cardiovascular sport paradox Moderate sport is good for health but intensive exercise can reveal CV disease RR sudden death 3 RR = 2, p< ,3 Trained Sedentary Y.O. Corrado et al. J Am Coll Cardiol ,9

4 Cardiovascular preparticipation screening before competitive sport (1) CV PPS aims detection of cardiac disease with - an increased SD risk - a risk of worsening with intensive sport practice

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

6 The athlete s heart syndrome - Clinical signs - ECG signs False positive ECG - Echocardiographic signs

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

8 What is an athlete? All sport competitors are not athletes Athlete 6-8 h/week of intensive sport since 6 months

9 Athlete s ECG: the level of training Parameters Sedentary Low level training < 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, Early Repolarization, 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0,5% 1% 40% Negative T waves 2% 2.3% 2.7% Pelliccia et al Circulation 2000, Pellicica A et al Eur Heart J 2007, Unpublished personal data

10 Densité (%) Athlete s ECG physiopathology Autonomic nervous system adaptations Cyclis tes Parasympathetic * ** Untrained Trained Sympathetic Récepteurs Récepteurs Récepteurs bêta1 bêta2 bêta3 Cyclists Carré F et al Untrained Barbier J et al Med. Sci Sports Exerc 2004

11 Athlete s ECG physiopathology Intrinsic cardiomyocytes adaptations J N Johnson Br J Sports Med 2009 Jew KN et al. J Appl Physiol 2001: TRN Sedentary AP duration SED Trained tones R, et al. Basic Res Cardiol ;2009 :104 : Stones R, et al. Basic Res Cardiol ;2009 :104 :643-52

12 ECG variants in athletes Asymptomatic athlete with no family history of sudden cardiac death and with an adapted level of performance Common ECG changes in AH Sinus bradycardia AVB first degree Incomplete RBBB Isolated electrical LVH Early repolarization pattern Uncommon ECG changes in AH Left atrial enlargment Right ventricular hypertrophy Marked QRS axis deviation Complete BBB Pathological Q waves Ventricular preexcitation Ventricular arrhythmias Brugada like repolarisation Negative T waves ST segment depression Long or short QTc Modified from Corrado D et al. Eur Heart J 2010

13 Athlete s heart: a multifactorial adaptation Training specificities Anthropometry Gender Age Ethnicity Genetic Doping

14 Athlete s ECG: gender effect Pelliccia A et al Circulation 2000

15 Common ECG changes in athlete s heart Right bundle branch block (1)

16 Common ECG changes in athlete s heart Right bundle branch block (2)

17 Common ECG changes in athlete s heart Isolated left ventricular hypertrophy

18 Common ECG changes in athlete s heart Sinus bradycardia HR= 35 bpm

19 Common ECG changes in athlete s heart Respiratory arrhythmia

20 Common ECG changes in athlete s heart Junctional rythm

21 Common ECG changes in athlete heart Sinus bradycardia and SV ectopic ryhm Endurance athletes +++ No correlation with sport performance bpm 2-3% < 40 bpm Holter recordings Untrained Sedentary Trained Cyclist Day Night Day Night

22 Common ECG changes in athlete s heart Atrioventricular blocks first degree ++ No correlation with bradycardia Correlation with training periods AVB % y.o. asymptomatic LD runner 5 Holters 0 Training sesions E IT C R A I C R E= endurance, IT= interval-training, C= competition, R = recovery

23 Common ECG changes in athlete s heart Second degree with Lucianni-Wenckebach period AVB Modern pentathlon 30 yo

24 Common ECG changes in athlete s heart Repolarization patterns T waves are positive except in avr, D3 and V1

25 Common ECG changes in athlete s heart Repolarization patterns (2) Bifid T waves

26 Common ECG changes in athlete s heart Repolarization patterns (3) Typical early repolarization

27 Common ECG changes in athlete s heart Repolarization patterns (4) J wave syndrom «slurring» pattern

28 Common ECG changes in athlete s heart Repolarization patterns (5) J wave syndrom «notching» pattern

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

30 QTc duration in athletes, which limits? 5130 athletes 3514 males 1676females Kervio G et al Europrevent 2009 Limits Males Females ESC 2005 (> ) 129 (3.7%) 31 (1.9%) Bethesda 2005 ( ) 16 (0.4%) 9 (0.5%)

31 QTc Limits of Bazett correction for QT duration in athletes RR 1200 ms (n=730) RR > 1200 ms (n=178) QTc Bazett Kervio G et al Europrevent 2009 Heart rate (bpm)

32 Uncommon ECG changes in athlete s heart J point upward / Diphasic T waves

33 Repolarization abonormalities in a caucasian woman long distance runner (1) Deep inverted T waves

34 Repolarization abonormalities in a caucasian long distance runner (2) Echocardiography = normal Cardiac MRI : mild HCM

35 CV- PPS in Athlete History,physical exam, NO ABNORMALITY 12 leads-ecg Normal Training related changes Training unrelated changes Sinus bradycardia AVB 1 IRBBB Isolated LVH Early repolarisation 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 CV clearance for intensive sport Adapted CV exams Temporary/definitive disqualification for intensive sport