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Electrocardiographic Interpretation in Athletes

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Electrocardiographic Interpretation in Athletes Electrocardiographic Interpretation in Athletes Donald F. Kreuz, MD, FACC Columbia University Cardiac Disease and SCD in Athletes • Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sports – ≈1/100,000 athletes per year • Mostly hereditary, structural or electrical cardiac disorders – HCM (20%), Congenital coronary anomalies (15-20%) – Myocarditis, valvular, dilated cardiomyopathy, ruptured aortic aneurysm, premature CAD and ARVC (4-5% each) – WPW, ion channelopathies (2-3% each) • May not be clinically apparent but may be identified or suggested by abnormalities on an ECG 2 Electrocardiographic Interpretation in Athletes • Objectives – Identify on ECG normal variants and exercise-related physiological changes in athletes – Identify on ECG pathologic or suggestive changes of cardiac disorders predisposing athletes to SCD • Outline I. Reading of 15 ECG tracings II. CV Screening Recommendations to Prevent SCD in Athletes III. Recommendation for ECG Interpretation in Athletes IV. Review of the 15 ECG tracings 3 HR PR QRS QTc Axis 40 170 114 486 52 396 ECG 1 24yo White Female Runner HR PR QRS QTc Axis 36 194 118 492 89 380 ECG 2 20yo White Male Swimmer HR PR QRS QTc Axis 57 244 102 446 117 434 ECG 3 28yo White Male Runner HR PR QRS QTc Axis 58 158 104 442 74 433 ECG 4 19yo White Male Triathlete HR PR QRS QTc Axis 56 144 98 430 35 414 ECG 5 24yo Black Male Basketball Player HR PR QRS QTc Axis 50 170 90 442 31 402 ECG 6 21yo White Female Soccer Player HR PR QRS QTc Axis 45 * 80 480 -37 415 ECG 7 20yo Black Male Soccer Player HR PR QRS QTc Axis 56 100 112 436 60 421 ECG 8 18yo White Female Swimmer HR PR QRS QTc Axis 55 116 132 400 -36 382 ECG 9 18yo White Male Distance Runner HR PR QRS QTc Axis 65 152 88 370 84 384 ECG 10 21yo White Male Football Player HR PR QRS QTc Axis 71 168 78 390 99 423 ECG 11 19yo White Female Basketball Player HR PR QRS QTc Axis 45 164 114 478 64 413 ECG 12 25yo White Male Triathlete HR PR QRS QTc Axis 81 246 146 371 -81 431 ECG 13 28yo White Male Power Lifter HR PR QRS QTc Axis 75 175 117 363 36 405 ECG 14 23yo Asian Male Golfer HR PR QRS QTc Axis 79 174 140 438 -9 502 ECG 15 21yo White Male Distance Runner CV Screening Recommendations to Prevent SCD in Athletes Younger Athletes North American European (12-35years) Pre-Participation Complete Personal History Complete Personal History History and Physical Family History Family History Physical Examination Physical Examination ECG Routine not recommended Routine recommended History/PE screening+ ECHO, Exercise Routine not recommended Routine not recommended testing, others History/PE screening+ History/PE screening+ Abnormal routine ECG+ 19 14-Element CV Screening Checklist for Heart Disease American Heart Association, American College of Cardiology – Personal history – Family history • 1. Chest pain, discomfort, tightness, • 8. Premature death (sudden and pressure related to exertion unexpected, or otherwise) before 50y of age • 2. Unexplained syncope, near- attributable to heart disease in ≥1 relative syncope • 9. Disability from heart disease in close • 3. Excessive and unexplained relative <50y of age dyspnea, fatigue or palpitations, • 10. Hypertrophic or dilated cardiomyopathy, associated with exercise LQTS, or other ion channelopathies, Marfan, • 4. Prior recognition of a heart or clinically significant arrhythmias; genetic murmur cardiac conditions in family members • 5. Elevated systemic BP – Physical examination • 6. Prior restriction from participation • 11. Heart murmur in sports • 12. Femoral pulses (aortic coarctation) • 7. Prior testing for the heart, ordered • 13. Physical stigmata of Marfan syndrome by a physician • 14. Brachial artery BP (sitting position) 20 Pre-participation Physical Evaluation Monograph The American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports 21 NCAA: Inter-association Consensus Statement on CV Care of College Student-Athletes (2016) • Routine, large-scale use of ECGs is not recommended. • However many member institutions utilize ECG as part of pre-participation cardiac screening. • The following guidance is provided: – ECG should be obtained with proper equipment and by trained persons. – ECG should be interpreted with modern standards that distinguish normal findings related to physiological cardiac remodeling in trained athletes from abnormalities suggestive of an underlying pathological cardiac condition. – The institution should provide cardiology oversight and resources, either on-site or at a regional referral center, to interpret suspicious ECGs and guide and perform secondary testing. 22 Recommendations for ECG Interpretation in Athletes • 2010 European Society of Cardiology Recommendations for ECG interpretation in Athletes • 2012 Summit on ECG Interpretation in Athletes in Seattle, Washington “Seattle Criteria” • 2017 International Recommendations for ECG Interpretation in Athletes – Reduction of false positive rate 17% to 4.2% without affecting sensitivity 23 JACC International Recommendations for ECG Interpretation in Athletes (2017) Sanjay Sharma et al. JACC 2017;69:1057-1075 24 JACC International Recommendations for ECG Interpretation in Athletes (2017) • Normal ECG Findings in Athletes – Athlete: an individual who engages in regular intensive exercise or training for sport or general physical fitness, typically with a goal of improving performance • Age 12-35 • Asymptomatic (no cardiac symptoms) • No family history for genetic cardiovascular disease or premature SCD – Training-related ECG alterations: physiologic adaptations to regular exercise • Enlarged cardiac chamber size and increased vagal tone • Considered normal variants in athletes • Do not require further evaluation 25 Normal ECG Findings in Athletes • No further evaluation required – Isolated increased QRS voltage for RVH or LVH – Incomplete Right Bundle Branch Block (RBBB) – Early Repolarization/ST Segment Elevation – ST Elevation followed by T-wave Inversion in V1-V4 in African American Athletes – T-wave Inversion in leads V1-V3 less than age 16 – Sinus Bradycardia or Sinus Arrhythmia – Ectopic Atrial or Junctional Rhythm – First-degree AV Block – Second-degree AV Block Mobitz Type 1 26 Normal ECG Findings in Athletes • Isolated increased QRS voltage for LVH – Without other associated ECG abnormalities • S V1 + R V5-6 >35mm (Sokolow-Lyon) • LR aV >11mm (Sokolow-Lyon) • S V3 + R aVL >28mm M, > 20mm F (Cornell) – Significant variations due to sex, race, body habitus and age (<35 criteria not well- established) – Common in young athletes 27 Normal ECG Findings in Athletes • Isolated increased QRS voltage for RVH – Without other associated ECG abnormalities • R V1 + S V5-6 >10.5mm (Sokolow) • R V1 >7mm (Myers) – 13% of athletes 28 Normal ECG Findings in Athletes • Incomplete Right Bundle Branch Block – ECG findings: • V1 rSR, wide R • V6 qRS, wide S • I Wide S • QRS duration: <0.12 sec – Common in young athletes 29 Normal ECG Findings in Athletes • Early Repolarization/ST segment Elevation – Common in healthy population – Higher in young, male – Athletes (45% W, >63% AA) – ECG Findings: • J point elevated > 0.1mV; notching • ST elevation upward concave pattern • Tall peaked T wave • No reciprocal depression 30 • Early Repolarization in ECG of a 29yo M asymptomatic soccer player: − Sinus bradycardia (44 beats/min) − Early repolarization in I, II, aVF, V2-V6 ( arrows ) − LVH voltage criterion (SV1 + RV5 >35 mm) − Tall, peaked T waves (circles ) • These are common, training related findings in athletes and do not require more evaluation. Sanjay Sharma et al. JACC 2017;69:1057-1075 The Authors Normal ECG Findings in Athletes • Repolarization Variant in African-American Athletes – Considered normal variant in the absence of clinical or other ECG features of cardiomyopathy – ECG Findings: • J-point elevation • Convex ST-segment elevation • Followed by T-wave inversion • Anterior leads V1-V4 32 • Anterior Repolarization Changes in ECG from a black athlete demonstrating: − LVH voltage criterion − J-point elevation − Convex (‘domed’) ST-segment elevation − Followed by T-wave inversion in V1-V4(circles ) • This is a normal repolarization pattern in black athletes. Sanjay Sharma et al. JACC 2017;69:1057-1075 The Authors Normal ECG Findings in Athletes • Juvenile (age 12-16) Pattern – Normal age-related pattern • Aged 12:10-15% • Aged 14-15: 2.5% • Aged >16 or completed puberty: <0.1% – ECG findings • T-wave inversion or bi-phasic • Anterior precordial leads only (V1-3) 34 Normal ECG Findings in Athletes • Physiological Arrhythmias in Athletes – Increased vagal tone – Sinus rhythm should resume and bradycardia should resolve with onset of physical activity 35 Normal ECG Findings in Athletes • Physiological Arrhythmias in Athletes – Sinus Bradycardia (>30bpm) or Sinus Arrhythmia – Ectopic Atrial or Junctional Rhythm – First-degree AV block – Second-degree AV block Mobitz Type 1 36 JACC International Recommendations for ECG Interpretation in Athletes (2017) • Normal ECG Findings: – Athlete • Age 12-35 • Asymptomatic • No family history of inherited cardiac diseases or sudden cardiac death – Considered normal variants in athletes or physiologic adaptations to regular exercise – No further evaluation 37 JACC International Recommendations for ECG Interpretation in Athletes (2017) • Borderline ECG Findings in Athletes – Athlete: • Age 12-35
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