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%) – , valvular, dilated , 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 , associated with exercise LQTS, or other ion channelopathies, Marfan, • 4. Prior recognition of a heart or clinically significant ; 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 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 (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 or Sinus – Ectopic Atrial or – 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 • No reciprocal depression

30 • Early Repolarization in ECG of a 29yo M asymptomatic soccer player: − (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 • Asymptomatic (no cardiac symptoms) • No family history for genetic cardiovascular disease or premature SCD – Previously categorized as abnormal – May represent normal variants or result of physiological cardiac remodeling in athletes • Usually do not represent pathological cardiac disease • In isolation, no further evaluation – 2 or more findings however require further evaluation

38 Borderline ECG Findings in Athletes

• In isolation: No further evaluation required – (LAD) – (RAD) – Left (LAE) – Right Atrial Enlargement (RAE) – Complete Right Bundle Branch Block (RBBB) • 2 or more: Further evaluation required

39 Borderline ECG Findings in Athletes

• LAD • RAD  -30 to -90  +90 to +180

Lead I pos (R) Lead I neg (rS)

Lead AVF: Lead AVF: pos (R) neg (rS, QS)

40 Borderline ECG Findings in Athletes

• Left Atrial Enlargement: – Increased P-wave Width (>0.12s) – Diphasic V1 • 2nd half negative (depth >1mm) • Wide (>0.04s) – Notched • Wide, notched I, II (>0.12s) • Tall I>III

41 Borderline ECG Findings in Athletes

• Right Atrial Enlargement – Increased P-wave Amplitude (>2.5mm) – Peaking • Pointed II, III, AVF • Tall III>I

42 Borderline ECG Findings in Athletes

• Complete Right Bundle Branch Block – ECG Findings: • V1 rSR, wide R • V6 qRS, wide S • I Wide S • Complete: >0.12 sec – 0.5-2.5% in young adult athletes

43 JACC International Recommendations for ECG Interpretation in Athletes (2017) • Borderline ECG Findings: – Athlete • Age 12-35 • Asymptomatic • No family history of inherited cardiac diseases or sudden cardiac death – May represent normal variants or physiological cardiac remodeling in athletes. – In isolation, no further evaluation – 2 or more findings however require further evaluation

44 JACC International Recommendations for ECG Interpretation in Athletes (2017)

• Abnormal ECG Findings – Not recognized features of athletic training – Always require further assessment to exclude intrinsic cardiac disease.

45 Abnormal ECG Findings in Athletes

• Further evaluation required – Complete (LBBB) – QRS > 140 msec duration – Pathologic Q waves – Ventricular Pre-excitation – T-wave Inversion – ST Segment Depression – Epsilon wave – Brugada Type 1 pattern

46 Abnormal ECG Findings in Athletes

• Further evaluation required – Prolonged QT Interval – Profound Sinus Bradycardia <30 beats per minute – Profound First-degree AV Block (PR >400 msec) – Second-degree AV Block Mobitz Type 2 – Third-degree AV Block – 2 or more Premature Ventricular Contractions – Atrial Tachyarrhythmias – Ventricular Arrhythmias

47 Abnormal ECG Findings in Athletes

• Complete Left Bundle Branch Block – ECG Findings: • QRS ≥120ms

• Predominantly negative QRS complex in lead V1 (QS or rS)

• Upright notched or slurred R wave in leads I and V6

48 Abnormal ECG Findings in Athletes

• Profound Nonspecific Intra-Ventricular Conduction Delay (IVCD) – Any QRS duration ≥140 msec

49 Abnormal ECG Findings in Athletes

• Pathologic Q waves – Q/R ratio ≥0.25 or duration ≥40ms in two or more contiguous leads – Excludes III and aVR – Note: check lead placement (e.g. V1-2 due to high lead placement)

50 Abnormal ECG Findings in Athletes

• Ventricular Pre-excitation – ECG Findings: • Short PR interval <120 msec • Delta wave (slurred upstroke in the QRS complex) • Wide QRS (≥120 msec)

51 Abnormal ECG Findings in Athletes

• Ventricular Pre-excitation: WPW – General • 0.2% Population • Accessory AV pathway (Kent bundle) – Clinical features • Asymptomatic • Tachyarrhythmia/Palpitations

52 Abnormal ECG Findings in Athletes

• T- Wave Inversion – ≥1 mm in depth in two or more contiguous leads • Anterior leads (V2-4) with exceptions • Lateral leads (I and AVL, V5 and/or V6) – Only one lead of TWI required in V5 or V6 • Inferior leads (II and aVF)

53 Abnormal ECG Findings in Athletes

• T- Wave Inversion – Excludes leads aVR, III, V1 – Excludes Anterior leads • Black athletes with J-point elevation and convex ST- segment elevation followed by TWI in V2–V4 (Repolarization variant) • Athletes age <16 with TWI in V1–V3 (Juvenile pattern)

54 • Examples of Physiological and Pathological T-wave Inversion − (A) Physiological T-wave inversion in V1-V4 (variant repolarization in AA athletes  Preceded by J-point elevation and convex ‘domed’ ST-segment elevation (circles ) − (B) Pathological T-wave inversion in V1-V6  Absent J-point elevation and a downsloping ST-segment (circles ).

Sanjay Sharma et al. JACC 2017;69:1057-1075 The Authors Abnormal ECG Findings in Athletes

• ST Segment Depression – ≥0.5 mm in depth in two or more contiguous leads – Not a feature of athletic training

56 Abnormal ECG Findings in Athletes

• Epsilon Wave – ECG Findings: • Distinct low amplitude signal (small positive deflection or notch) • Between the end of the QRS complex and onset of the T-wave in

leads V1–V3

57 Abnormal ECG Findings in Athletes

• Epsilon Wave: Arrhythmogenic Right Ventricular Dysplasia (ARVD) – General • Northern Italy, France, Germany, Japan – Clinical presentation • Palpitations during exertion • PVCs • Syncope • SCD as first manifestation rare • RV arrhythmias, failure

58 Abnormal ECG Findings in Athletes

• Epsilon Wave: Arrhythmogenic Right Ventricular Dysplasia (ARVD) – ECG Findings: • Epsilon wave (arrows ) • T wave inversion in V1-V3 • QRSd >100msec in V1-V3 • Absence of J-point elevation • Depressed ST segment • Prolonged S wave upstroke • Low limb lead voltage • Ectopy with LBBB

59 Abnormal ECG Findings in Athletes

• Brugada Type 1 Pattern – ECG Findings in V1-V3: • Coved rSr’ pattern • ST-segment elevation – Initial ≥2 high take-off – then down sloping • Negative symmetric T-wave

60 Abnormal ECG Findings in Athletes

• Brugada Type 1 Pattern – Autosomal dominant • Na channel mutations – Clinical presentation • Male predominance • Endemic in Southeast Asia • Sudden unexpected nocturnal death syndrome

61 • Differentiation Between the Brugada ECG Pattern From Early Repolarization in Athletes − Vertical lines mark the STJ (J-point) and the ST80 (point 80 ms after the J-point), where amplitudes of the ST-segment elevation are calculated.

− Left: Brugada Type 1  ‘Downsloping” ST-segment elevation is characterized by a STJ/ST80 ratio >1

− Right: Early repolarization  J Point elevation and Convex ST segment elevation  Initial ‘Upsloping’ ST-segment elevation with STJ/ST80 ratio <1.

Sanjay Sharma et al. JACC 2017;69:1057-1075

The Authors Abnormal ECG Findings in Athletes

• Prolonged QT interval – ECG Findings • QTc ≥470 ms (Male) • QTc ≥480 ms (Female) • QTc ≥500 ms (marked QT prolongation)

63 QT Interval Measurement

• QT interval correction – Heart rates between 60 and 90 bpm • Heart rate <50: Repeat ECG after mild aerobic activity • Heart rate >100: Repeat ECG after a longer resting period – Use Bazett’s formula QTc = QT÷

– Use lead II or𝑅𝑅𝑅𝑅 V5 – Use teach-the-tangent method to avoid inclusion of U-wave

64 • Teach-the-Tangent’ or ‘Avoid-the-Tail’ Method for Manual Measurement of QT Interval − A straight line is drawn on the downslope of the T-wave to the point of intersection with the isoelectric line. − The U-wave is not included in the measurement.

Sanjay Sharma et al. JACC 2017;69:1057-1075

The Authors Abnormal ECG Findings in Athletes

• Profound Sinus Bradycardia <30 beats/min • Sinus Pauses ≥3 sec – >15 big boxes

• Profound 1° AV Block (PR interval ≥400 msec) – >2 big boxes

66 Abnormal ECG Findings in Athletes

• High Grade AV Block – 2° AV Block Mobitz Type II • Intermittently non-conducted P waves with a fixed PR interval

– 3° AV (Complete) Block

67 Abnormal ECG Findings in Athletes

• Atrial Tachyarrhythmias – Supraventricular (SVT)

– Atrial (AF)

–

68 Abnormal ECG Findings in Athletes

• PVC – ≥2 PVCs per 10 sec tracing • Ventricular Arrhythmias – Couplets – Triplets – Non-sustained

69 Abnormal ECG Findings in Athletes

• Considerations in Athletes >30 years of Age – CAD most common cause of SCD – Resting ECG has low sensitivity for CAD – Look for ECG patterns suggesting underlying CAD: • TWI, ST segment depression • Pathological Q waves • RBBB or LBBB or LAH • Abnormal R wave progression • AF – Review CAD risks e.g. lipid, hypertension, smoking, DM, family history of MI or sudden death

70 JACC International Recommendations for ECG Interpretation in Athletes (2017)

• Abnormal ECG Findings – Not recognized features of athletic training – Always require further assessment to exclude intrinsic cardiac disease.

71 JACC International Recommendations for ECG Interpretation in Athletes (2017) • Limitations of ECG – Anomalous coronary arteries – Premature coronary atherosclerosis – Aortopathies (aortic root dilation) – Some particularly ARVC

72 HR PR QRS QTc Axis 40 170 114 486 52 396 ECG 1 24yo White Female Runner ✓

Sinus Bradycardia HR PR QRS QTc Axis 36 194 118 492 89 380 ECG 2 20yo White Male Swimmer ✓

Sinus Bradycardia HR PR QRS QTc Axis 57 244 102 446 117 434 ECG 3 28yo White Male Runner ✓ Sinus Bradycardia

RAD Axis +117

First-Degree AV Block PR 244 HR PR QRS QTc Axis 58 158 104 442 74 433 ECG 4 19yo White Male Triathlete ✓

Sinus Bradycardia

Early Repolarization: J point elevation ST elevation V2-V4 with Tall Peaked T wave HR PR QRS QTc Axis 56 144 98 430 35 414 ECG 5 24yo Black Male Basketball Player ✓

Sinus Bradycardia

Anterior Repolarization in AA Athlete: Domed ST elevation V1-3 followed by T-wave inversion HR PR QRS QTc Axis 50 170 90 442 31 402 ECG 6 21yo White Female Soccer Player ✘

Sinus Bradycardia

T-wave Inversion aVL Flat T-wave Lead I

T-wave Inversion V1-V3 HR PR QRS QTc Axis 45 * 80 480 -37 415 ECG 7 20yo Black Male Soccer Player ✘

Sinus Bradycardia

T-wave Inversion I, aVL

LAD T-wave Inversion Axis -37 V2-V6

2nd-Degree AV Block Type I HR PR QRS QTc Axis 56 100 112 436 60 421 ECG 8 18yo White Female Swimmer ✘

Sinus Bradycardia

RAE LAE Tall Peaked P-wave (2.5mm) Inverted P-wave (40ms wide Lead II, II, AVF and 1mm deep) V1 HR PR QRS QTc Axis 55 116 132 400 -36 382 ECG 9 18yo White Male Distance Runner ✘

Sinus Bradycardia

Q wave WPW: II, III, AVF Short PR Interval (116) Delta wave Wide QRS (132)

LAD Axis -36 HR PR QRS QTc Axis 65 152 88 370 84 384 ECG 10 21yo White Male Football Player ✘

LAE Inverted P-wave (40ms wide and 1mm deep) V1

T-wave Inversion or biphasic V4-V6

T-wave Inversion II, III, AVF HR PR QRS QTc Axis 71 168 78 390 99 423 ECG 11 19yo White Female Basketball Player✘

RAD RVH Axis +99 R wave V1 >7

ST Depression and T-wave Inversion II, III, AVF HR PR QRS QTc Axis 45 164 114 478 64 413 ECG 12 25yo White Male Triathlete ✘

Sinus Bradycardia

ST Depression T-wave flat, biphasic T-wave Inversion II, III, AVF V3-V6 HR PR QRS QTc Axis 81 246 146 371 -81 431 ECG 13 28yo White Male Power Lifter ✘

RBBB Complete

LAD Axis -81

LAHB 1st-Degree AV Block Poor R progression HR PR QRS QTc Axis 75 175 117 363 36 405 ECG 14 23yo Asian Male Golfer ✘

Brugada: Coved ST-segment Elevation T-wave Inversion V1-V2 HR PR QRS QTc Axis 79 174 140 438 -9 502 ECG 15 21yo White Male Distance Runner ✘

LBBB

LAD Axis -81 LAE Inverted P-wave (40ms wide and 1mm deep) V1 References

• Journal of the American College of Cardiology. February 2017. International Recommendations for Electrocardiographic Interpretation

• Journal of the American College of Cardiology. Volume 67, Issue 25, June 2016. Inter-association Consensus Statement on Cardiovascular Care of College Student- Athletes. Brian Hainline, Jonathan A. Drezner, Aaron Baggish

• AHA/ACC Assessment of ECG as Screening Test for Detection of CV Disease in Health General Populations of Young People. A Scientific Statement. Barry J Maron, MD

• Electrocardiographic interpretation in athletes: the ‘Seattle Criteria’

• BMJ Learning ECG interpretation in athletes. Drezner J. http://learning.bmj.com/learning/course-intro/.html?courseId=10042239

• UptoDate, Screening to Prevent SCD in Athletes, 2018

88 Thank You

Donald F. Kreuz, MD, FACC Columbia University