Recommendations for interpretation of 12-lead electrocardiogram in the athlete

Abstract

Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed.

Ventricular Arrhythmias in Young Competitive Athletes: Prevalence, Determinants, and Underlying Substrate

“…Similar to the nonathletic general population, VAs in the athletes may be associated with an underlying myocardial substrate potentially at risk of SCD. Current guidelines recommend that athletes with VAs should undergo further clinical and imaging workup to exclude an underlying pathologic substrate on the basis of a high number and complexity of PVBs 2, 3. Our results suggest that a multiparametric approach considering VA morphologic features, complexity, and relation to exercise, rather than the PVBs count alone, is useful for differentiating between benign and other potentially pathologic variants.…”

“…As a consequence, to detect ventricular arrhythmias (VAs) on the athlete's ECG raises concern of an underlying cardiac disease at risk of SCD 2, 3. Interpretation of VA in athletes with no overt structural abnormalities is still a matter of debate.…”

Signs of RV overload on the athlete’s ECG

“…The ECG ( This case depicts another clinical scenario in which the load on the right heart is increased. Although the combination of right ventricular hypertrophy on voltage criteria and right axis deviation has been observed in up to 0.5% of young athletes in the absence of structural heart disease [25], both the ESC criteria and more recently proposed Seattle criteria for athlete ECG interpretation suggest that in combination, these findings are suspicious for the presence of pulmonary hypertension and should trigger further investigation in the athlete as the increased RV afterload may predispose athletes to the development of RV failure and increase the risk of sudden death [3,13]. Although the finding of low limb lead voltages is not discussed in either criteria, seen together with RVH and RAD the index of suspicion for the presence of underlying structural heart disease in this case was high.…”

“…Although these adaptations are generally considered the expression of adaptive physiology in athletes, it is often challenging to reliably distinguish these from abnormal ECG findings related to potentially lethal cardiovascular conditions due to their phenotypic overlap. For this purpose, ECG interpretation guidelines classify ECG changes as either those which are common and training related ("group 1") or those thought to be uncommon, training unrelated, and which warrant further investigation to exclude cardiac pathology ("group 2") [3,4]. Nevertheless, recent data have shown that even group 2 ECG findings are not so uncommon in highly-trained endurance athletes, particularly those ECG features suggestive of right ventricular (RV) pathology such as deep T-wave inversion (TWI) in the right precordial leads and voltage criteria for RV hypertrophy [2].…”

“…In adults with idiopathic pulmonary arterial hypertension, 87% demonstrated RVH and 79% demonstrated right axis deviation [15]. Current European Society of Cardiology guidelines recommend that Sokolow-Lyon RVH should prompt further assessment for 'pathological RV dilatation/ hypertrophy' in young athletes [3]. Nevertheless, a recent study in asymptomatic young athletes demonstrated that Sokolow-Lyon RVH was present in around one in eight athletes, indicating that such a strategy would be associated with an unacceptably high rate of false positive screening outcomes [16].…”