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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 • • • • • • • • 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 • • • • • 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