Download Reading an athlete`s ECG: from ESC to Seattle and beyond

Sports Cardiology in Practice
Reading an athlete’s ECG:
from ESC to Seattle
and beyond
Domenico Corrado, MD, PhD
Inherited Arrhytmogenic Cardiomyopathy Unit
Department of Cardiac, Thoracic and Vascular Sciences,
University of Padova, Italy
[email protected]
1st International course in Sports Cardiology
St George’s University of London, UK- August 28, 2015
ECG abnormalities in the athlete
•  ECG changes in athletes are common and usually
reflect morphofunctional remodelling of the heart as
an adaptation to regular physical training (athlete’s
heart).
•  However, rarely abnormalities of athlete’s ECG may
be an expression of an underlying heart disease at risk
of sudden arrhythmic death during sport.
•  It is imperative that ECG abnormalities resulting
from intensive physical training and those potentially
associated with an increased cardiovascular risk are
properly defined.
A decade of athlete ECG criteria:
Where we’ve come and where we’re going
Baggish AL, Journal of Electrocardiology 2015; 48:324–328
A decade of athlete ECG criteria:
Where we’ve come and where we’re going
Baggish AL, Journal of Electrocardiology 2015; 48:324–328
Corrado et al. Eur Heart J 2005
Corrado et al JAMA 2006;296:1593-1601
Sudden death per 100000 person-years
Annual Incidence Rates of Sudden Cardiovascular Death in
Screened Competitive Athletes and Unscreened Nonathletes
Aged 12 to 35 Years in the Veneto Region of Italy
(1979-2004)
4,5
4
Athletes
Nonathletes
3,5
3
2,5
P for trend <0.001
2
1,5
1
0,5
0
1979- 1981- 1983- 1985- 1987- 1989- 1991- 1993- 1995- 1997- 1999- 2001- 20031980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Years
Corrado et al JAMA 2006;296:1593-1601
Screening of young athletes for
Cardiovascular diseases
(Center for Sports Medicine, Padua 1979-2004)
Athletes screened
42,386
Positive findings
3,914 (9%)
False positive
≈ 9%
Heart diseases
879 (2%)
False positive
≈ 7%
Potentially lethal
heart diseases
91 (0.2%)
Corrado et al JAMA 2006; 296: 1593-1601
A decade of athlete ECG criteria:
Where we’ve come and where we’re going
Baggish AL, Journal of Electrocardiology 2015; 48:324–328
How to interprete 12-lead ECG in the athlete
PERSPECTIVE
•  Appropriate interpretation of athlete’s ECG
requires the distinction of two main groups of
abnormalities based on:
–  prevalence,
–  relation to exercise training,
–  inherent cardiovascular risk,
–  and need for further clinical investigation to
confirm (or exclude) an underlying cardiovascular
disease
Corrado et al. Eur Heart J 2010;31:243–259
Clinical significance of abnormal ECG
patterns in trained athletes
Pelliccia et al. Circulation. 2000;102:278-84
Pure increased QRS voltages
(Sokolow-Lyon criteria for LVH)
A decade of athlete ECG criteria:
Where we’ve come and where we’re going
Baggish AL, Journal of Electrocardiology 2015; 48:324–328
EGC interpretation in athletes: the ‘Seattle
Normal ECG’findings in athletes
Abnormal ECG findings in athletes
Criteria
Drezner JA, et al. Br J Sports Med
2013;47:122–124
Brosnan et al. Br J Sports Med 2014;48:1144–1150
A decade of athlete ECG criteria:
Where we’ve come and where we’re going
Baggish AL, Journal of Electrocardiology 2015; 48:324–328
CRY refined criteria
Sheikh et al. Circulation 2014;129:1637-1649
Importance of appropriate interpretation
of athlete’s ECG
•  The importance of distinguishing ECG abnormalities
due to the normal athletic heart from heart disease has
profound implications.
•  Athletes may undergo expensive diagnostic work-up or
may be unnecessarily disqualified from competition for
abnormalities that fall within the normal range for
athletes (specificity).
•  Alternatively, signs of potentially lethal cardiovascular
disorders may be misinterpreted as normal variants of
an athlete's ECG (sensitivity).
Corrado et al. Eur Heart J 2010;31:243–259
Isolated increase of QRS voltages
•  According to the ESC recommendation for athlete’s
ECG interpretation, the ECG changes due to cardiac
adaptation to physical exertion, predominantly the
physiologic increase of QRS voltages, should not cause
alarm and the athlete should be allowed to participate
in sports without additional evaluation.
•  Although this ECG interpretation approach offers the
potential to lower the traditional high number of false
positives and to reduce unnecessary and expensive
investigations, whether and to what extent the
increased specificity alter the ECG sensitivity for HCM
remains to be established.
Calore C …Corrado D. Int J Cardiol 2013;168:4494-4497
*
* Group 2: the “isolated increase of QRS voltage group” exhibiting a pure increase of QRS amplitude
according to the Sokolow-Lyon criteriona (but no other ECG abnormalities);
Group 3: the “abnormal ECG group” showing ≥1 criteria for atrial enlargement, QRS axis deviation,
QRS prolongation, ST-segment or T-wave abnormalities, and abnormal
Q wave (regardless of QRS voltages).
Calore C …Corrado D. Int J Cardiol 2013;168:4494-4497
Calore C …Corrado D. Int J Cardiol 2013;168:4494-4497
Corrado et al. Eur Heart J 2010;31:243–259
Cardiovascular causes of sudden death
associated with sports
Adults (age > 35 years):
Atherosclerotic coronary artery disease
Young competitive athletes (age ≤35 years):
Hypertrophic cardiomyopathy
Arrhythmogenic right ventricular cardiomyopathy
Congenital anomalies of coronary arteries
Myocarditis
Aortic rupture
Valvular disease
Preexcitation syndromes and conduction diseases
Ion channel diseases
Congenital heart disease, operated or unoperated
Leading causes of sudden cardiovascular
death in young competitive athletes
HCM
ARVC/D
Prevalence of right precordial T-wave inversion
at preparticipation ECG screening:
a prospective study on 2765 asymptomatic children
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Study population: 2765 consecutive children
Gender: 1914 M (70%)
Age: mean 13.9±2.2 yrs; median, 14 years; range 8-18 yrs
T-wave inversion beyond V1(overall): 131 (4.7%)
–  72 (2.6%) in leads V1 and V2
–  59 (2.1%) in leads V1 to V3 or beyond
T-wave inversion (ath.≥14 years ): 26/1521 (1.7%)
p<.001
T-wave inversion (ath.<14 years ): 105/1244 (8.4%)
ARVC/D diagnosis (Echo/cardiac MR): 3 of 131 (2.3%)
ARVC/D prevalence in this population: 0.1%
Migliore F…Corrado D, Circulation 2012:125:529-538
ECG and echocardiographic findings
in a 14-year-old male
Juvenile pattern of repolarization
According to ESC recommendations,
T-wave inversion beyond V1 is seen in postpubertal athletes less commonly than
previously thought (1.5%), but deserves
special consideration because it may reflect
underlying ARVC
Corrado et al. Eur Heart J 2010;31:243–259
A
Right precordial early repolarization
B
L1
V1
V2
L2
V2
L3
V3
L3
V3
aVR
V4
aVR
V4
aVL
V5
aVL
V5
aVF
V6
aVF
V6
L1
V1
L2
Corrado et al. Eur Heart J 2010;31:243–259
Drezner JA, et al. Br J Sports Med 2013;47:122–124
Calore C…Corrado D (submitted to Eur Heart J)
An up-sloping ST-segment configuration (STJ/ST80<1) showed a sensitivity of 97%,
a specificity of 100% and a diagnostic accuracy of 98.7% for the diagnosis of ER
Zorzi A…Corrado D, Am J Cardiol 2015;115:529-532
Revised «Seattle Criteria» 2015
Interna7onal Consensus Standards for ECG Interpreta7on in Athletes Normal ECG Findings • Increased QRS voltage for LVH or RVH • Incomplete RBBB • Early repolariza=on/ST segment eleva=on • ST eleva=on followed by T wave inversion V1-­‐V4 in black athletes • T wave inversion V1-­‐V3 ≤ age 16 years old • Sinus bradycardia or arrhythmia • Ectopic atrial or junc=onal rhythm • 1° AV block • Mobitz Type I 2° AV block Abnormal ECG Findings Borderline ECG Findings • 
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LeP axis devia=on LeP atrial enlargement Right axis devia=on Right atrial enlargement Complete RBBB In isola=on No further evalua7on required in asymptoma=c athletes with no family history of inherited cardiac disease or SCD • T wave inversion • ST segment depression • Pathologic Q waves • Complete LBBB • QRS ≥ 140 ms dura=on • Ventricular pre-­‐excita=on • Prolonged QT interval • Brugada Type 1 paVern • Profound sinus bradycardia < 30 bpm • PR interval ≥ 400 ms • Mobitz Type II 2° AV block • 3° AV block • ≥ 2 PVCs • Atrial tachyarrhythmias • Ventricular arrhythmias 2 or more Further evalua7on required to inves=gate for pathologic cardiovascular disorders associated with SCD in athletes Conclusions
•  Refinement of current ECG screening criteria
has the potential to further reduce the burden
of false positive ECGs in athletes
•  In assessing the double-edged duality of ECG
preparticipation screening – cost versus
effectiveness- it is critical to consider that
prevention is not about saving money, it is
about saving lives
Appropriate interpretation of the athlete's
electrocardiogram saves lives as well as money
Corrado D, McKenna WJ. Eur Heart J 2007 ;28:1920-2