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ECG IN ATHLETS

An athlete is defined as an individual who engages in regular exercise or training for sport or general fitness, typically with a premium on performance, and often engaged in individual or team competition at least 4 8 hours per week

The majority of disorders associated with an increased risk of CSD in athletes may be recognized by abnormalities in the ECG In the presence of cardiac symptoms or a family history of inherited cardiovascular disease or premature SCD, the interpretation standards may require modification. The ECG can not detect the presence of congenital abnormalities of the coronary arteries, early coronary artery disease and aortic disorders. Finally, low disease prevalence limits the positive predictive value of many ECG criteria, even for those with otherwise favorable sensitivity and specificity Τα πρότυπα ερµηνείας ενδέχεται να απαιτούν τροποποίηση

ECG abnormalities in athletes 1) ECG changes that are common and related to chronic exercise 2) ECG changes unusual and unrelated to the exercise Eur Heart J (2010) 31 (2): 243-259

Recommendations for interpretation of 12-lead electrocardiogram in the athlete Domenico Corrado Eur Heart J (2010) 31 (2): 243-259

From: Recommendations for interpretation of 12-lead electrocardiogram in the athlete Eur Heart J. 2009;31(2):243-259. doi:10.1093/eurheartj/ehp473 Eur Heart J Published on behalf of the European Society of Cardiology. All rights reserved. The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org

the Seattle Criteria I

the Seattle Criteria II

International recommendations for electrocardiographic interpretation in athletes

International consensus standards for ECG interpretation in athletes. AV, atrioventricular; LBBB, left bundle branch block; LVH, left ventricular hypertrophy; PVC, premature ventricular contraction; RBBB, right bundle branch block; RVH, right ventricular hypertrophy; SCD, sudden cardiac death. Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731

athletes with abnormal ECG findings of uncertain clinical significance should be recommended temporary absence from athletic activity until the completion of further examinations are required for the investigation.

NORMAL ECG FINDINGS IN ATHLETES Left and right ventricular hypertrophy Early repolarization juvenile electrocardiographic pattern Physiological arrhythmias of athletes

ECG demonstrates incomplete RBBB with rsr pattern in V1 and QRS duration of <120 ms. represents a phenotype of cardiac adaptation to exercise Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731

sinus bradycardia + early repolarization + hypertrophy From: International recommendations for electrocardiographic interpretation in athletes Eur Heart J. Published online February 20, 2017. doi:10.1093/eurheartj/ehw631 Eur Heart J The Author 2017. This article has been co-published in the European Heart Journal and the Journal of the American College of Cardiology. An extended version of this article has also been jointly published in the British Journal of Sports Medicine.

juvenile electrocardiographic pattern negative or biphasic T in leads beyond V2 on teen ECG Occurs in 10-15% of adolescent white athletes aged 12 years and in 2.5% of adolescent white athletes aged 14-15. negative T in leads beyond V2 in white athletes> 16 years is rare (0.1%)

hypertrophy, J point elevation and convex ( domed ) ST segment elevation followed by T-wave inversion in V1 V4 From: International recommendations for electrocardiographic interpretation in athletes Eur Heart J. Published online February 20, 2017. doi:10.1093/eurheartj/ehw631 Eur Heart J The Author 2017. This article has been co-published in the European Heart Journal and the Journal of the American College of Cardiology. An extended version of this article has also been jointly published in the British Journal of Sports Medicine.

T-wave inversion From: International recommendations for electrocardiographic interpretation in athletes Eur Heart J. Published online February 20, 2017. doi:10.1093/eurheartj/ehw631 Eur Heart J The Author 2017. This article has been co-published in the European Heart Journal and the Journal of the American College of Cardiology. An extended version of this article has also been jointly published in the British Journal of Sports Medicine.

Physiological arrhythmias of athletes Manifestations of Increased Vagal Tone Sinus bradycardia 30 bpm respiratory sinus arrhythmia Nodal or ectopic atrial rhythms Mobitz I prolonged PR interval up to 300 ms Atrioventricular dissociation without block.

A 28-year-old asymptomatic Caucasian handball player demonstrating a junctional escape rhythm (red arrows). QRS rate is faster than the resting P wave or sinus rate, which is typically slower in athletes Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731 Copyright BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.

ECG shows Mobitz type I (Wenckebach) second-degree AV block demonstrated by progressively longer PR intervals until there is a non-conducted P-wave (arrows) and no QRS complex. greater disturbance of AV nodal conduction Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731 1:1 conduction should return with the onset of exercise.

ectopic atrial rhythm. Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731 Ectopic P waves are most easily seen when the P waves are negative in the inferior due leads to a slowed resting sinus rate from increased vagal tone in athletes to 8% of all athletes

Borderline ECG findings in athletes Axis deviation and voltage criteria for atrial enlargement Complete RBBB

ECG from an asymptomatic 22-year-old black male athlete demonstrating complete right bundle branch block (QRS 120 ms), left axis deviation ( 57 ) and right atrial enlargement (P wave 2.5 mm in II and avf). Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731, the presence of more than one of these borderline findings in combination places the athlete in the abnormal category warranting additional investigation

PATHOLOGICAL EKG FINDINGS Ι Pathological negative T (negative T with depth 1 mm in at least 2 adjacent leads) Biphasic T when their negative part has a depth 1 mm in at least two adjacent leads. Negative T in lateral and lower lateral leads Exceptions: black athletes with elevation, white athletes <16 years, biphasic T only V3

ECG from a 30-year-old patient with ARVC showing anterior TWI in V1-V3 preceded by a flat or downsloping ST segment without J-point elevation. Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731

(A) ECG from an 18-year-old black basketball player demonstrating abnormal TWI extending into V5. Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731

Examples of physiological (A) and pathological T wave inversion (TWI) (B). Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731

ECG in a young athlete with arrhythmogenic right ventricular cardiomyopathy showing several abnormal features including anterior T wave inversion (V1 V4) preceded by a nonelevated J-point and ST segment, an epsilon wave in V1 (magnified and marked with arrow), delayed S wave upstroke in V2, and low voltage (<5 mm) QRS complexes in limb leads I and avl. Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731

ECG from a patient with arrhythmogenic right ventricular cardiomyopathy. Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731

PATHOLOGICAL EKG FINDINGS ΙΙ ST depression Pathological Waves Q LBBB Nonspecific intraventricular delay (QRS range 140 ms) ventricular prexcitation QT prolongation Type I Bruganda Mobitz II, complete atrioventricular block Atrial flutter and atrial fibrillation ventricular arrhythmias

coronary artery disease is rare in individuals <40 years of age, whereas coronary anomalies tend not to be associated with myocardial infarction. Recommended that HCM criteria for Q waves be used in young athletes (>3 mm in depth and/ or >40 ms duration in any lead except AVR, III, and V1). We do not endorse the use of standard coronary disease criteria for Q waves in young athletes, but they should apply in athletes >40 years of age

ECG from an 18-year-old female swimmer demonstrating deep and wide pathological Q waves in V4-V6, I and avl. Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731 hypertrophic cardiomyopathy 32% 42% of patients.

ECG with complete LBBB demonstrating a QRS 120 ms, predominantly negative QRS complex in lead V1, upright R wave in leads I and V6, and ST segments and T waves in the opposite direction of the QRS. LBBB is always an abnormal finding in athletes and warrants a comprehensive evaluation to exclude myocardial disease. LBBB, left bundle branch block. Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731 less than 1 in 1000 athletes

Long-QT interval QTc value of 500 ms, unexplained, is indicative of unequivocal LQTS, regardless of family history and symptoms. QTc intervals >440 ms (males)/460 (females) and <500 ms represent a grey zone which requires detailed assessment QTc >470 ms in men or 480 ms in women needs further evaluation for long-qt syndrome. QTc intervals shorter than 340 ms should also lead to further evaluation ECG screening and QTc interval measurement of family members. mutation analysis.

This figure illustrates the Teach-the-Tangent or Avoid-the-Tail method for manual measurement of the QT interval. Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731

Brugada type 1 ECG (left) should be distinguished from early repolarisation with convex ST segment elevation in a trained athlete (right). Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731 Corrado index STJ/ST80 ratio >1 Brugada pattern STJ/ST80 ratio <1 early repolarisation

ECG demonstrating the classic findings of Wolf-Parkinson-White pattern with a short PR interval (<120 ms), delta wave (slurred QRS upstroke) and prolonged QRS (>120 ms). Jonathan A Drezner et al. Br J Sports Med 2017;51:704-731 rapid conduction of atrial fibrillation across the accessory pathway can result in VF.

Cost Effectiveness of Screening Modalities EKG is most costeffective To be equally cost- Effective: Hx/PE need 2x inc in sensitivity Echo needs 4 x decrease in cost FULLER: Med Sci Sports Exerc, Volume 32(5).May 2000.887-890

Mandatory ECG Screening (?) reduce the risk of SCD Israel Sport Authority Results compared 12 yrs before & after 1997 legislation Mandatory screening with resting ECG & exercise testing Mandatory ECG screening of athletes had no apparent effect on the risk of cardiac death Before 1997 11 2.54 events 1985-2009 After 1997 13 2.66 events p=0.88 Steinvil, et.al. JACC. 2011; 57: 1291-1296

Annual Incidence of Sudden Cardiac Death Expressed per 100,000 Person- Years in the 3 Studies Evaluating the Effects of Screening on the Mortality of Athletes Over Time Steinvil, et.al. JACC. 2011; 57: 1291-1296

Barriers to routine ECG-based screening Large number of athletes for the size of appropriate physician work force Lack of standardization for interpretation of ECGs in athletes Lack of normative data in certain demographic and ethnic group

NBA Mandatory Screening 2006 Season Consists of Personal & Family Hx PE Blood work EKG Resting echo Stress echo Administered annually No training camp until complete

CONCLUSIONS Prevention of SCD in athletes remains a highly visible topic in sports medicine and cardiology. Cardiac adaptation and remodeling from regular athletic training produces common ECG alterations that could be mistaken as abnormal. physicians responsible for the cardiovascular care of athletes be guided by ECG interpretation standards that improve disease detection and limit false-positive results..

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