EKG in athletes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]


Overview

Corrado et al. have published an ESC consensus document on the screening of athletes for competitive sports.[1] Besides a good medical history and examination, a 12 lead EKG is also part of the screening. They have set up special EKG criteria for participants in competitive sports (table 1). If one of the described findings are present on the EKG, the EKG is considered 'positive' and further evaluation is mandatory which can include echocardiography, 24-h ambulatory Holter monitoring, and exercise testing. EKG Features of cardiac diseases detectable at pre-participation screening in young competitive athletes are shown in table 2. [1] [2] [3] [4] [5] [6] [7]

Prevalence of EKG abnormalities in competitive athletes has been studied by Pellicia et al.[2](see table below). EKG abnormalities in their study increased with age and level of exercise. In young amateur athletes they found EKG abnormalities in about 7%, a number that rised to 40% in "adult elite athletes". Especially RBBB and left ventricular hypertrophy were often seen.

Recently fierce debate has been going on about whether an EKG should be part of the screening of apparently healthy young sporters. In Italy this screening is compulsory by law and this country is a strong advocate of the use of an EKG as part of this screening. However, others[6] have stated that costs are too high for the yield (expressed in dollars per prevented sudden cardiac death) and an EKG is not included in the screening protocol of the American Heart Association.[3] [4]

Criteria for a positive EKG

Table 1: Criteria for a positive 12-lead EKG
P wave
  • left atrial enlargement: negative portion of the P wave in lead V1 ≥ 0.1 mV in depth and ≥ 0.04 s in duration
  • right atrial enlargement: peaked P wave in leads II and III or V1 ≥ 0.25 mV in amplitude
QRS complex
  • frontal plane axis deviation: right ≥ +120° or left –30° to –90°;
  • increased voltage: amplitude of R or S wave in in a standard lead ≥2 mV, S wave in lead V1 or V2 ≥ 3 mV, or R wave in lead V5 or V6 ≥ 3 mV;
  • abnormal Q waves ≥ 0.04 s in duration or ≥ 25% of the height of the ensuing R wave or QS pattern in two or more leads;
  • right or left bundle branch block with QRS duration ≥ 0.12 s;
  • R or R' wave in lead V1 ≥ 0.5 mV in amplitude and R/S ratio ≥ 1.
ST-segment, T-waves, and QT interval
  • ST-segment depression or T-wave flattening or inversion in two or more leads;
  • prolongation of heart rate corrected QT interval (QTc) > 0.44 s in males and > 0.46 s in females.c
Rhythm and conduction abnormalities
  • premature ventricular beats or more severe ventricular arrhythmias;
  • supraventricular tachycardias, atrial flutter, or atrial fibrillation;
  • short PR interval (< 0.12 s) with or without ‘delta’ wave;
  • sinus bradycardia with resting heart rate ≤ 40 beats/min;a
  • first (PR ≥ 0.21 sb), second or third degree atrioventricular block.
  • aIncreasing less than 100 beats/min during limited exercise test.
  • bNot shortening with hyperventilation or limited exercise test.
  • cA recent study suggests athletes with a QTc > 500ms should be recommended not to participate in competitive sports[5] [7]

Cardiac diseases and their EKG features

Table 2: EKG Features of cardiac diseases detectable at pre-participation screening in young competitive athletes
Disease QTc interval P wave PR interval QRS complex ST interval T wave Arrhythmias
HCM Normal (left atrial enlargement) Normal Increased voltages in mid-left precordial leads; abnormal Q waves in inferior and / or lateral leads; (LAD, LBBB); (delta wave) Down-sloping (up-sloping) Inverted in mid-left precordial leads; (giant and negative in the apical variant) (Atrial fibrillation); (PVB); (VT)
Arrhythmogenic right ventricular cardiomyopathy / Arrhythmogenic right ventricular dysplasia Normal Normal Normal Prolonged > 110 ms in right precordial leads; epsilon wave in right precordial leads; reduced voltages <= 0.5 mV in frontal leads; (RBBB) (Up-sloping in right precordial leads) Inverted in right precordial leads PVB with a LBBB pattern; (VT with a LBBB pattern)
Dilated cardiomyopathy Normal (Left atrial enlargement) (Prolonged >= 0.21s) LBBB Down-sloping (up-sloping) Inverted in inferior and / or lateral leads PVB; (VT)
Long QT syndrome Prolongedc
  • > 440ms in males
  • > 460ms in females
Normal Normal Normal Normal Bifid or biphasic in all leads (PVB); (torsade de pointes)
Brugada Syndrome Normal Prolonged >= 0.21s S1S2S3 pattern; (RBBB/LAD) Up-sloping coved-type in right precordial leads Inverted in right precordial leads (Polymorphic VT); (atrial fibrillation) (sinus tachycardia)
Lenègre disease Normal Normal Prolonged >= 0.21s RBBB; RBBB/LAD; LBBB Normal Secondary changes (2nd or 3rd degree AV block)
Short QT syndrome Shortened < 300 ms Normal Normal Normal Normal Normal Atrial fibrillation (polymorphic VT)
Pre-excitation syndrome (WPW) Normal Normal Shortened < 0.12s Delta wave Secondary changes Secondary changes Supraventricular tachycardia; (atrial fibrillation)
Coronary artery diseasesa (Prolonged) Normal Normal (Abnormal Q waves)b (Down-or up-sloping) Inverted in >= 2 leads PVB; (VT);
  • Less common or uncommon EKG findings are reported in brackets.
  • QTc: QT interval corrected for heart rate by Bazett’s formula. LBBB: left bundle branch block. RBBB: right bundle branch block. LAD: left axis deviation of –30 degrees or more. PVB: either single or coupled premature ventricular beats. VT: either non-sustained or sustained ventricular tachycardia.
  • aCoronary artery diseases: either premature coronary atherosclerosis or congenital coronary anomalies.
  • bAbnormal Q waves (table 1)
  • cA recent study suggests athletes with a QTc > 500ms should be recommended not to participate in competitive sports[5] [7]

Prevalence of EKG abnormalities in athletes

Table 3: Prevalence of EKG abnormalities in an unselected population of 32 652 young individuals undergoing the pre-participation cardiovascular screening
EKG abnormalities Athletes, n (%)
Negative T-waves in precordial/standard leads 751 (2.3)
RBBB 351 (1.0)
Increased R/S wave voltages (suggestive of LVH) 247 (0.8)
Left anterior fascicular block 162 (0.5)
Pre-excitation pattern 42 (0.1)
LBBB 19 (0.1)
Prolonged corrected QT interval 1 (0.003)
Others (incomplete RBBB, prolonged PR interval, early repolarization pattern) 2280 (7.0)
Total 3853 (11.8)
  • RBBB, right bundle branch block; LVH, left ventricular hypertrophy; LBBB, left bundle branch block.[2]

References

  1. 1.0 1.1 Corrado D, Pelliccia A, Bjørnstad HH, Vanhees L, Biffi A, Borjesson M, Panhuyzen-Goedkoop N, Deligiannis A, Solberg E, Dugmore D, Mellwig KP, Assanelli D, Delise P, van-Buuren F, Anastasakis A, Heidbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E, Blomstrom-Lundqvist C, McKenna WJ, Thiene G; Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005 Mar;26(5):516-24. PMID 15689345
  2. 2.0 2.1 2.2 Pelliccia A, Culasso F, Di Paolo FM, Accettura D, Cantore R, Castagna W, Ciacciarelli A, Costini G, Cuffari B, Drago E, Federici V, Gribaudo CG, Iacovelli G, Landolfi L, Menichetti G, Atzeni UO, Parisi A, Pizzi AR, Rosa M, Santelli F, Santilio F, Vagnini A, Casasco M, Di Luigi L. Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Heart J. 2007 Aug;28(16): 2006-10. PMID 17623682
  3. 3.0 3.1 Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, Dimeff R, Douglas PS, Glover DW, Hutter AM Jr, Krauss MD, Maron MS, Mitten MJ, Roberts WO, Puffer JC; American Heart Association Council on Nutrition, Physical Activity, and Metabolism. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007 Mar 27;115(12):1643-455. PMID 17353433
  4. 4.0 4.1 Myerburg RJ, Vetter VL. Electrocardiograms should be included in preparticipation screening of athletes. Circulation. 2007 Nov 27; 116 (22): 2616-26. PMID 18040041
  5. 5.0 5.1 5.2 Moss AJ. What duration of the QTc interval should disqualify athletes from competitive sports? Eur Heart J. 2007 Dec;28 (23): 2825-6. PMID 17967824
  6. 6.0 6.1 Chaitman BR. An electrocardiogram should not be included in routine preparticipation screening of young athletes. Circulation. 2007 Nov 27; 116 (22): 2610-4. PMID 18040040
  7. 7.0 7.1 7.2 Basavarajaiah S, Wilson M, Whyte G, Shah A, Behr E, Sharma S. Prevalence and significance of an isolated long QT interval in elite athletes. Eur Heart J. 2007 Dec;28(23):2944-9. PMID 17947213

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  • ECGpedia

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