HK

Dr. H .

Regular physical exercise is

associated with a decrease in all
cause-mortality, particularly from
cardiovascular causes

vigorous exertion may acutely and

transiently increase the risk of acute
coronary events and sudden cardiac
arrest in susceptible Individuals

Causes of sudden cardiac death in young athletes

the most common

mechanism of SCD during
sports activity is an abrupt
ventricular tachyarrhythmia
as a consequence of a wide
spectrum of cardiovascular
diseases

Papadakis M et al. BMJ 2008;337:bmj.a1596

pre-participation cardiovascular screening recommended by the

European Society of Cardiology section of Sports Cardiology

Corrado D et al. Eur Heart J 2011;32:934-944

Annual incidence of sudden cardiovascular death in screened

competitive athletes compared with non-athletes in Veneto
region, Italy, 1979-2004.

adding ECG to history and physical examination in the screening

protocol of athletes aged 1422 years saves

2.06 life-years per 1000 athletes,

at a cost of $42,000 per life-year saved

Athletes heart

up to 60% of athletes demonstrate ECG changes

Regular and long-term participation in intensive exercise (minimum of 4
h/week) is associated with unique electrical manifestations that reflect
increased vagal tone and enlarged cardiac chamber size.
The extent of these changes is also dependent on

the athletes ethnicity,

age,
gender,
sporting discipline and level of training and competition

These ECG findings in athletes are considered normal, physiological

adaptations to regular exercise and do not require further evaluation

Concerns for the physician when interpreting an

athletes ECG

missing a dangerous cardiac condition and

generating false-positive interpretations
that cause

needless further investigations,

increased economic cost and
potentially unnecessary activity restriction for
the athlete.

Drezner JA, et al. Br J Sports Med 2013;47:122124.

The Seattle Criteria

The effect of the use of the proposed modern criteria

is
to substantially increase the ECG specificity (by 70%),
primarily in the important group of athletes who exhibit pure
voltage criteria for left ventricular hypertrophy and early
repolarization abnormalities, but
with the important requisite of maintaining sensitivity for
detection of cardiovascular diseases predisposing to SCD
during sports.
The criteria were developed with consideration of ECG
interpretation in the context of an asymptomatic athlete age
1435

Drezner JA, et al. Br J Sports Med 2013;47:122124.

Drezner JA, et
al. Br J Sports
Med
2013;47:122

Corrado et al. European Heart Journal (2010) 31, 243259

common and training-related ECG

changes

Classic definition of early repolarisation based on ST elevation at QRS end (J-point).

Drezner J A et al. Br J Sports Med 2013;47:125-136

Isolated increase of QRS voltages

Physiological LV hypertrophy in trained athletes usually manifests as an

isolated increase of QRS amplitude, with normal QRS axis, normal atrial
and ventricular activation patterns, and normal ST-segment T-wave
repolarization
LV hypertrophy differed with respect to

the type of sports discipline

and was more frequent in athletes engaged in endurance disciplines, such
as cycling, cross-country skiing, and rowing/canoeing.
male gender and
increased cardiac dimensions and wall thickness.

very uncommon finding in HCM patients

do not require systematic echocardiographic evaluation, unless they
have relevant symptoms, a family history of cardiovascular diseases,
and/or SCD or non-voltage ECG criteria suggesting pathological LV
hypertrophy.

Isolated increase of QRS voltages

ECG of a 29-year-old asymptomatic soccer player

Drezner J A et al. Br J Sports Med 2013;47:125-136

Increased QRS Voltage

The largest proportion of athletes with

ECGs classified as abnormal using
previous criteria exhibited isolated
increases in QRS voltage (prevalence of
up to 80% in some series).

uncommon and
training-unrelated ECG changes

T wave inversion

T-wave inversion >2 mm in two or more adjacent leads in an athlete

T-wave inversion in inferior (II, III, aVF) and/or lateral (I, aVL, V5V6)
leads must raise the suspicion of

ischaemic heart disease, cardiomyopathy, aortic valve disease, systemic

hypertension, and LV non-compaction

The post-pubertal persistence of T-wave inversion beyond V1 may

reflect an

is a non-specific warning sign of a potential cardiovascular disease at risk of

SCD during sports

underlying congenital heart disease leading to a RV volume or pressure

overload state, ARVC, and uncommonly, an inherited ion-channel disease.

Recent studies showed that T-wave inversion beyond V1 is seen in

post-pubertal athletes less commonly than previously thought (,1.5%),
but deserves special consideration because it may reflect underlying
ARVC

Abnormal ECG in a patient with hypertrophic cardiomyopathy.

Drezner J A et al. Br J Sports Med 2013;47:137-152

ECG from a patient with arrhythmogenic right ventricular cardiomyopathy.

Drezner J A et al. Br J Sports Med 2013;47:137-152

ECG from a patient with arrhythmogenic right ventricular cardiomyopathy showing delayed S
wave upstroke in V1 (arrow), low voltages in limb leads <5mm (circles), and inverted T waves
in anterior precordial leads (V1V4) and inferior leads (III and aVF).

Drezner J A et al. Br J Sports Med 2013;47:137-152

athletes of African/Caribbean origin

inverted T-waves, usually preceded by ST-segment

elevation,

commonly observed in leads V2V4 (up to 25% of cases)

and
represent adaptive early repolarization changes which
normalize during exercise or adrenergic stimulation.

On the contrary, T-wave inversion in inferior (L2, L3,

aVF) and/or lateral leads (L1, aVL, V5, and V6) are
uncommon even in black athletes and warrant further
investigation for excluding an underlying heart
disease.

ECG from a 17-year-old black/African soccer player demonstrating domed ST elevation

followed by T wave inversion in leads V1V4 (circles).

Drezner J A et al. Br J Sports Med 2013;47:137-152

Normal variant repolarisation changes in a black/African athlete characterised by domed ST

segment elevation and T wave inversion in V1V4.

Drezner J A et al. Br J Sports Med 2013;47:137-152

ST segment depression

extremely rare in otherwise healthy athletes

Any degree of ST depression beyond 0.5mm

in two or more leads is significant and
requires further investigation for
cardiomyopathy

Pathological Q waves

define Q waves for HCM as >3mm in depth or

>40ms in duration in at least two leads
(excluding leads III and aVR)
This detects HCM with a sensitivity of 35%
and a specificity of 95% in patients with
preclinical HCM based on molecular genetic
diagnosis

Abnormal ECG in a patient with hypertrophic cardiomyopathy.

Drezner J A et al. Br J Sports Med 2013;47:137-152

Left atrial enlargement

ECG in a patient with hypertrophic cardiomyopathy showing left atrial enlargement

LAE is defined as a prolonged P wave duration of >120ms in leads I or II with negative

portion of the P wave 1mm in depth and 40ms in duration in lead V1.
LAE on ECG is an uncommon finding in athletes and should prompt additional investigation.

Intraventricular conduction delay

Demonstration of complete bundle branch block

and/or hemiblock in an athlete should lead to a
cardiological work-up

(RBBB) is found more commonly in HCM than in athletes but

the frequency of incomplete and complete RBBB in athletes
is felt to limit its differentiating value.

marked non-specific IVCD >140ms is considered

abnormal and should prompt further evaluation
The significance of a non-specific intraventricular
conduction delay (IVCD) with normal QRS
morphology is uncertain.

Abnormal ECG in a patient with hypertrophic cardiomyopathy showing complete left bundle
branch block (QRS120ms with predominantly negative QRS complex in lead V1).

Drezner J A et al. Br J Sports Med 2013;47:137-152

Isolated premature ventricular contractions

multiple PVCs (2 or more) during a single ECG tracing (10 s), multifocal
PVCs or PVCs found in tandem with other abnormal ECG findings
likelihood is very high that the athlete has >2000 PVCs per 24 h.
In athletes with >2000 PVCs per 24 h, underlying structural heart
disease which may predispose to more lifethreatening ventricular
arrhythmias was found in 30% of cases,

compared to only 3% of athletes with 1002000 PVCs, and

0% of athletes with <100 PVCs on a 24 h Holter.

Over half of the athletes with >2000 PVCs also had bursts of
nonsustained ventricular tachycardia.
Therefore, a structural cardiac abnormality should be ruled out
in athletes with >2000 PVCs per 24 h.

ECG from a patient with arrhythmogenic right ventricular cardiomyopathy.

Drezner J A et al. Br J Sports Med 2013;47:137-152

Right atrial enlargement and right

ventricular hypertrophy

uncommon findings in athletes

SokolowLyon voltage criteria for RV hypertrophy (RVI+S-V5>10.5 mm) were seen in 0.6% professional
soccer players

should not be interpreted as a manifestation of

exercise-induced cardiac remodelling

ECG from a patient with pulmonary hypertension

Accuracy of ECG interpretation by specialty before and after criteria tool.

Drezner J A et al. Br J Sports Med 2012;46:335-340

Accuracy of ECG interpretation by diagnosis.

Drezner J A et al. Br J Sports Med 2012;46:335-340

.
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,

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http://learning.bmj/ECGathlete