Normal electrocardiographic findings: recognising physiological adaptations in athletes

Abstract

Electrocardiographic changes in athletes are common and usually reflect benign structural and electrical remodelling of the heart as a physiological adaptation to regular and sustained physical training (athlete's heart). The ability to identify an abnormality on the 12-lead ECG, suggestive of underlying cardiac disease associated with sudden cardiac death (SCD), is based on a sound working knowledge of the normal ECG characteristics within the athletic population. This document will assist physicians in identifying normal ECG patterns commonly found in athletes. The ECG findings presented as normal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

Cardiovascular adaptation in athletes

“…To differentiate from pathologic processes, such as inherited hypertrophic cardiomyopathies or arrhythmogenic right ventricular cardiomyopathy, ECG scoring systems have been developed by consensus to assist clinicians in differentiating normal adaptation from cardiac disease. [26][27][28] Athletic training, especially endurance training, also has profound effects on the autonomic nervous system, and these effects are manifest in alterations of cardiac electrophysiology. The primary autonomic alteration is an increase in parasympathetic tone, with resultant sinus bradycardia, sinus arrhythmia, first degree atrioventricular block and Mobitz I second degree atrioventricular block all common findings in the athlete.…”

Exercise ECG unmasked Brugada sign: manifestation of the risk of sports-associated sudden cardiac arrest (RCD code: V-1A.1)

“…SBP -systolic blood pressure, DBP -diastolic blood pressure, HR -heart rate exercise. Minimum of 4 hours a week of regular and long-term intensive physical activity corresponds to unique ECG characteristics which reflect increased vagal activity and cardiac chamber enlargement [14]. Those changes, among others, include first-degree AV block, incomplete RBBB and early repolarization (J-point elevation, J waves, concave ST-segment elevation or terminal QRS slurring) and are considered normal in athletes [14].…”

“…Those changes, among others, include first-degree AV block, incomplete RBBB and early repolarization (J-point elevation, J waves, concave ST-segment elevation or terminal QRS slurring) and are considered normal in athletes [14]. Moreover, in black/African athletes convex ('domed') ST-segment elevation with inverted T waves in V1-4 may be observed [14]. These ECG characteristics in athletes, especially rSr' QRS complexes, may be misleading in BrS diagnostic process [15].…”

“…Minimum of 4 hours a week of regular and long-term intensive physical activity corresponds to unique ECG characteristics which reflect increased vagal activity and cardiac chamber enlargement [14]. Those changes, among others, include first-degree AV block, incomplete RBBB and early repolarization (J-point elevation, J waves, concave ST-segment elevation or terminal QRS slurring) and are considered normal in athletes [14]. Moreover, in black/African athletes convex ('domed') ST-segment elevation with inverted T waves in V1-4 may be observed [14].…”

The Influence of Early Left Ventricle Remodeling Over QTC Changes in Highly Trained Preadolescent Footballers

“…In the same study, QTc prolongation also correlated with LV and RV mass and increased LV wall thickness. According to Sharma et al highly significantly prolonged QTc interval should be linked to the frequently registered ECG signs of left ventricle hypertrophy [14].…”