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Ferrari F, da Silveira AD, Ziegelmann PK, Aleixo H, Dilda GD, Emed LGM, Magalhães FCO, Cardoso FB, da Silva HC, Guerra FEF, Soares LG, Bassan F, Braga F, Herdy AH, Froelicher V, Stein R. Imaging associations enhance the understanding of ECG abnormalities in male Brazilian football players: findings from the B-Pro Foot ECG study. Br J Sports Med 2024; 58:598-605. [PMID: 38621858 DOI: 10.1136/bjsports-2023-108053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES To evaluate the prevalence of abnormal ECG findings and their association with imaging results in male Brazilian football players. METHODS The 'B-Pro Foot ECG' is a multicentre observational study conducted in 82 Brazilian professional clubs. It analysed 6125 players aged 15-35 years (2496 white, 2004 mixed-race and 1625 black individuals) who underwent cardiovascular screening from 2002 to 2023. All ECGs were reviewed by two experienced cardiologists in the athlete's care. Those with abnormal findings underwent further investigations, including a transthoracic echocardiogram (TTE). Cardiac magnetic resonance (CMR) was subsequently performed based on TTE findings or clinical suspicion. RESULTS In total, 180 (3%) players had abnormal ECGs and 176 (98%) showed normal TTE results. Athletes aged 26-35 years had a higher prevalence of abnormal ECGs than younger athletes (15-25 years). Black players had a higher prevalence of T-wave inversion (TWI) in the inferior leads than white players (2.6% vs 1.4%; p=0.005), as well as in V5 (2.9%) and V6 (2.1%) compared with white (1.2% and 1.0%; p<0.001) and mixed-race (1.5% and 1.2%; p<0.05) players, respectively. TTE parameters were similar across ethnicities. However, four out of 75 players with inferolateral TWI showed abnormal TTEs and CMR findings consistent with cardiomyopathies. CMR also showed cardiomyopathies or myocarditis in four players with inferolateral TWI and normal TTEs. In total, nine (0.1%) athletes were diagnosed with cardiac diseases and were followed for 40±30 months, with no cardiac events documented. CONCLUSION This study found a 3% prevalence of abnormal ECGs in male Brazilian football players. Inferolateral TWI was associated with cardiac pathologies confirmed by CMR, even in athletes with a normal TTE.
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Affiliation(s)
- Filipe Ferrari
- Graduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Exercise Cardiology Research Group (CardioEx), Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Anderson D da Silveira
- Graduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Exercise Cardiology Research Group (CardioEx), Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
- Science, Health and Performance Department, Grêmio Foot-Ball Porto Alegrense, Porto Alegre, RS, Brazil
| | - Patrícia K Ziegelmann
- Graduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Graduate Program in Epidemiology, Department of Statistics, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Haroldo Aleixo
- Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Luiz G M Emed
- Instituto de Neurologia de Curitiba, Curitiba, PR, Brazil
| | | | | | | | | | - Luciano G Soares
- Clínica Biocorfit Reabilitação Cardíaca Pulmonar e Metabólica, Goiânia, GO, Brazil
| | - Fernando Bassan
- Instituto Nacional de Cardiologia, Rio de Janeiro, RJ, Brazil
| | - Fabrício Braga
- Laboratorio de Performance Humana, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Artur H Herdy
- Instituto de Cardiologia de Santa Catarina, Florianópolis, SC, Brazil
| | - Victor Froelicher
- Department of Cardiovascular Medicine, Stanford University, Palo Alto, CA, USA
| | - Ricardo Stein
- Graduate Program in Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Exercise Cardiology Research Group (CardioEx), Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
- Internal Medicine Department, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Lasocka-Koriat Z, Lewicka-Potocka Z, Kaleta-Duss A, Siekierzycka A, Kalinowski L, Lewicka E, Dąbrowska-Kugacka A. Differences in cardiac adaptation to exercise in male and female athletes assessed by noninvasive techniques: a state-of-the-art review. Am J Physiol Heart Circ Physiol 2024; 326:H1065-H1079. [PMID: 38391314 DOI: 10.1152/ajpheart.00756.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 02/24/2024]
Abstract
Athlete's heart is generally regarded as a physiological adaptation to regular training, with specific morphological and functional alterations in the cardiovascular system. Development of the noninvasive imaging techniques over the past several years enabled better assessment of cardiac remodeling in athletes, which may eventually mimic certain pathological conditions with the potential for sudden cardiac death, or disease progression. The current literature provides a compelling overview of the available methods that target the interrelation of prolonged exercise with cardiac structure and function. However, this data stems from scientific studies that included mostly male athletes. Despite the growing participation of females in competitive sport meetings, little is known about the long-term cardiac effects of repetitive training in this population. There are several factors-biochemical, physiological and psychological, that determine sex-dependent cardiac response. Herein, the aim of this review was to compare cardiac adaptation to endurance exercise in male and female athletes with the use of electrocardiographic, echocardiographic, and biochemical examination, to determine the sex-specific phenotypes, and to improve the healthcare providers' awareness of cardiac remodeling in athletes. Finally, we discuss the possible exercise-induced alternations that should arouse suspicion of pathology and be further evaluated.
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Affiliation(s)
- Zofia Lasocka-Koriat
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Gdańsk, Poland
- First Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Zuzanna Lewicka-Potocka
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Gdańsk, Poland
- First Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Anna Kaleta-Duss
- Institute for Radiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Anna Siekierzycka
- Department of Medical Laboratory Diagnostics-Fahrenheit Biobank BBMRI.pl, Medical University of Gdańsk, Gdańsk, Poland
| | - Leszek Kalinowski
- Department of Medical Laboratory Diagnostics-Fahrenheit Biobank BBMRI.pl, Medical University of Gdańsk, Gdańsk, Poland
- BioTechMed Centre/Department of Mechanics of Materials and Structures, Gdańsk University of Technology, Gdańsk, Poland
| | - Ewa Lewicka
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Gdańsk, Poland
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Mauriello A, Roma AS, Ascrizzi A, Molinari R, Loffredo FS, D’Andrea A, Russo V. Arrhythmogenic Left Ventricular Cardiomyopathy: From Diagnosis to Risk Management. J Clin Med 2024; 13:1835. [PMID: 38610600 PMCID: PMC11012337 DOI: 10.3390/jcm13071835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/13/2024] [Accepted: 03/16/2024] [Indexed: 04/14/2024] Open
Abstract
PURPOSE OF REVIEW Left ventricular arrhythmogenic cardiomyopathy (ALVC) is a rare and poorly characterized cardiomyopathy that has recently been reclassified in the group of non-dilated left ventricular cardiomyopathies. This review aims to summarize the background, diagnosis, and sudden cardiac death risk in patients presenting this cardiomyopathy. RECENT FINDINGS Although there is currently a lack of data on this condition, arrhythmogenic left ventricular dysplasia can be considered a specific disease of the left ventricle (LV). We have collected the latest evidence about the management and the risks associated with this cardiomyopathy. SUMMARY Left ventricular arrhythmogenic cardiomyopathy is still poorly characterized. ALVC is characterized by fibrofatty replacement in the left ventricular myocardium, with variable phenotypic expression. Diagnosis is based on a multiparametric approach, including cardiac magnetic resonance (CMR) and genetic testing, and is important for sudden cardiac death (SCD) risk stratification and management. Recent guidelines have improved the management of left ventricular arrhythmogenic cardiomyopathy. Further studies are necessary to improve knowledge of this cardiomyopathy.
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Affiliation(s)
- Alfredo Mauriello
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—“V. Monaldi” Hospital, 80126 Naples, Italy; (A.S.R.); (A.A.); (R.M.); (F.S.L.); (A.D.); (V.R.)
- Unit of Cardiology, “Umberto I” Hospital, 84014 Nocera Inferiore, Italy
| | - Anna Selvaggia Roma
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—“V. Monaldi” Hospital, 80126 Naples, Italy; (A.S.R.); (A.A.); (R.M.); (F.S.L.); (A.D.); (V.R.)
| | - Antonia Ascrizzi
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—“V. Monaldi” Hospital, 80126 Naples, Italy; (A.S.R.); (A.A.); (R.M.); (F.S.L.); (A.D.); (V.R.)
| | - Riccardo Molinari
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—“V. Monaldi” Hospital, 80126 Naples, Italy; (A.S.R.); (A.A.); (R.M.); (F.S.L.); (A.D.); (V.R.)
| | - Francesco S. Loffredo
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—“V. Monaldi” Hospital, 80126 Naples, Italy; (A.S.R.); (A.A.); (R.M.); (F.S.L.); (A.D.); (V.R.)
| | - Antonello D’Andrea
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—“V. Monaldi” Hospital, 80126 Naples, Italy; (A.S.R.); (A.A.); (R.M.); (F.S.L.); (A.D.); (V.R.)
- Unit of Cardiology, “Umberto I” Hospital, 84014 Nocera Inferiore, Italy
| | - Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Science, University of Campania “Luigi Vanvitelli”—“V. Monaldi” Hospital, 80126 Naples, Italy; (A.S.R.); (A.A.); (R.M.); (F.S.L.); (A.D.); (V.R.)
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4
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Ilodibia TF, Riding N. Anterior T-wave inversion in black athletes: an African perspective. Br J Sports Med 2024; 58:295-296. [PMID: 38290797 DOI: 10.1136/bjsports-2023-107585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 02/01/2024]
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Petek BJ, Drezner JA, Churchill TW. The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions. Card Electrophysiol Clin 2024; 16:35-49. [PMID: 38280813 PMCID: PMC11207195 DOI: 10.1016/j.ccep.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan A Drezner
- University of Washington Medical Center for Sports Cardiology, Massachusetts General Hospital, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA 98195, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA.
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Corrado D, Anastasakis A, Basso C, Bauce B, Blomström-Lundqvist C, Bucciarelli-Ducci C, Cipriani A, De Asmundis C, Gandjbakhch E, Jiménez-Jáimez J, Kharlap M, McKenna WJ, Monserrat L, Moon J, Pantazis A, Pelliccia A, Perazzolo Marra M, Pillichou K, Schulz-Menger J, Jurcut R, Seferovic P, Sharma S, Tfelt-Hansen J, Thiene G, Wichter T, Wilde A, Zorzi A. Proposed diagnostic criteria for arrhythmogenic cardiomyopathy: European Task Force consensus report. Int J Cardiol 2024; 395:131447. [PMID: 37844667 DOI: 10.1016/j.ijcard.2023.131447] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 10/18/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a heart muscle disease characterized by prominent "non-ischemic" myocardial scarring predisposing to ventricular electrical instability. Diagnostic criteria for the original phenotype, arrhythmogenic right ventricular cardiomyopathy (ARVC), were first proposed in 1994 and revised in 2010 by an international Task Force (TF). A 2019 International Expert report appraised these previous criteria, finding good accuracy for diagnosis of ARVC but a lack of sensitivity for identification of the expanding phenotypic disease spectrum, which includes left-sided variants, i.e., biventricular (ABVC) and arrhythmogenic left ventricular cardiomyopathy (ALVC). The ARVC phenotype together with these left-sided variants are now more appropriately named ACM. The lack of diagnostic criteria for the left ventricular (LV) phenotype has resulted in clinical under-recognition of ACM patients over the 4 decades since the disease discovery. In 2020, the "Padua criteria" were proposed for both right- and left-sided ACM phenotypes. The presently proposed criteria represent a refinement of the 2020 Padua criteria and have been developed by an expert European TF to improve the diagnosis of ACM with upgraded and internationally recognized criteria. The growing recognition of the diagnostic role of CMR has led to the incorporation of myocardial tissue characterization findings for detection of myocardial scar using the late‑gadolinium enhancement (LGE) technique to more fully characterize right, biventricular and left disease variants, whether genetic or acquired (phenocopies), and to exclude other "non-scarring" myocardial disease. The "ring-like' pattern of myocardial LGE/scar is now a recognized diagnostic hallmark of ALVC. Additional diagnostic criteria regarding LV depolarization and repolarization ECG abnormalities and ventricular arrhythmias of LV origin are also provided. These proposed upgrading of diagnostic criteria represents a working framework to improve management of ACM patients.
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Affiliation(s)
- Domenico Corrado
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua Medical School, Italy.
| | - Aris Anastasakis
- Unit of Inherited and Rare Cardiovascular Diseases, Onassis Cardiac Surgery Center, Athens, Greece
| | - Cristina Basso
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua Medical School, Italy
| | - Barbara Bauce
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua Medical School, Italy
| | - Carina Blomström-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | - Alberto Cipriani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua Medical School, Italy
| | - Carlo De Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis, Brussel - Vrije Universiteit Brussel, Belgium
| | - Estelle Gandjbakhch
- Sorbonne Universitè, APHP, Centre de Référence des Maladies Cardiaques héréditaires Groupe Hospitalier Pitié Salpêtrière-Charles Foix, Paris, France
| | | | - Maria Kharlap
- Department of cardiac arrhythmias, National Centre for Therapy and Preventive Medicine, Moscow, Petroverigsky, Russia
| | - William J McKenna
- Institute of Cardiovascular Science, University College London, United Kingdom
| | - Lorenzo Monserrat
- Cardiovascular Genetics, Medical Department, Dilemma Solutions SL, A Coruña, Spain
| | - James Moon
- CMR Service, Barts Heart Centre, University College London, United Kingdom
| | - Antonis Pantazis
- Inherited Cardiovascular Conditions services, The Royal Brompton and Harefield Hospitals, London, United Kingdom
| | | | - Martina Perazzolo Marra
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua Medical School, Italy
| | - Kalliopi Pillichou
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua Medical School, Italy
| | - Jeanette Schulz-Menger
- Charité, Universitätsmedizin Berlin, Campus Buch - ECRC and Helios Clinics, DZHK Partnersite Berlin, Germany
| | - Ruxandra Jurcut
- Expert Center for Rare Genetic Cardiovascular Diseases, Institute for Cardiovascular Diseases "Prof.dr.C.C.Iliescu", UMF "Carol Davila", Bucharest, Romania
| | - Petar Seferovic
- University of Belgrade, Faculty of Medicine and Heart Failure Center, Belgrade University Medical Center, Belgrade
| | - Sanjay Sharma
- Cardiology Clinical Academic Group, St. George's, University of London, United Kingdom
| | - Jacob Tfelt-Hansen
- Section of Genetics, Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Denmark; Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Gaetano Thiene
- University of Padua Medical School, ARCA Associazione Ricerche Cardiopatie Aritmiche ETS, Padova, Italy
| | - Thomas Wichter
- Dept. of Internal Medicine / Cardiology, Heart Center Osnabrück - Bad Rothenfelde, Niels-Stensen-Kliniken, Marienhospital Osnabrück, Osnabrück, Germany
| | - Arthur Wilde
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Amsterdam, the Netherlands
| | - Alessandro Zorzi
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua Medical School, Italy
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Gasperetti A, James CA, Carrick RT, Protonotarios A, te Riele ASJM, Cadrin-Tourigny J, Compagnucci P, Duru F, van Tintelen P, Elliot PM, Calkins H. Arrhythmic risk stratification in arrhythmogenic right ventricular cardiomyopathy. Europace 2023; 25:euad312. [PMID: 37935403 PMCID: PMC10674106 DOI: 10.1093/europace/euad312] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 10/19/2023] [Indexed: 11/09/2023] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heritable cardiomyopathy characterized by a predominantly arrhythmic presentation. It represents the leading cause of sudden cardiac death (SCD) among athletes and poses a significant morbidity threat in the general population. As a causative treatment for ARVC is still not available, the placement of an implantable cardioverter defibrillator represents the current cornerstone for SCD prevention in this setting. Thanks to international ARVC-dedicated efforts, significant steps have been achieved in recent years towards an individualized, patient-centred risk stratification approach. A novel risk calculator algorithm estimating the 5-year risk of arrhythmias of patients with ARVC has been introduced in clinical practice and subsequently validated. The purpose of this article is to summarize the body of evidence that has allowed the development of this tool and to discuss the best way to implement its use in the care of an individual patient.
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MESH Headings
- Humans
- Risk Factors
- Arrhythmogenic Right Ventricular Dysplasia/complications
- Arrhythmogenic Right Ventricular Dysplasia/diagnosis
- Arrhythmogenic Right Ventricular Dysplasia/therapy
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Death, Sudden, Cardiac/epidemiology
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/therapy
- Arrhythmias, Cardiac/complications
- Defibrillators, Implantable/adverse effects
- Risk Assessment
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Affiliation(s)
- Alessio Gasperetti
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Blalock 545, 600 N. Wolfe St., Baltimore, MD 21287, USA
- Department of Genetics, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
- Department of Medicine, Division of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, Utrecht, The Netherlands
| | - Cynthia A James
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Blalock 545, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | - Richard T Carrick
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Blalock 545, 600 N. Wolfe St., Baltimore, MD 21287, USA
| | | | - Anneline S J M te Riele
- Department of Medicine, Division of Cardiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht, Utrecht, The Netherlands
| | - Julia Cadrin-Tourigny
- Cardiovascular Genetics Center, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
| | - Firat Duru
- Department of Cardiology, Arrhythmia Unit, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Peter van Tintelen
- Department of Genetics, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
| | - Perry M Elliot
- Department of Cardiology, UCL Institute of Cardiovascular Science, London, UK
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Blalock 545, 600 N. Wolfe St., Baltimore, MD 21287, USA
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Idiazabal-Ayesa U, Ramírez-Vélez R, Sanz-de la Garza M, Izquierdo M. Electrocardiographic findings in pediatric versus young-adolescent athletes: A comparative analysis using general international criteria. Int J Cardiol 2023; 390:131201. [PMID: 37482093 DOI: 10.1016/j.ijcard.2023.131201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND The inclusion of electrocardiogram (ECG) in medical examinations for sports practice serves as a valuable tool for identifying potential life-threatening conditions during physical exercise. However, its applicability in young individuals remains a subject of controversy, primarily due to relatively high rates of false positives and the associated costs of further investigations. Furthermore, the validation of International Criteria for athletes below 12 years of age in optimizing pre-participation screening for young athletes is yet to be established. In light of these considerations, this study aims to describe the prevalence of ECG findings in a sample of children and young-adolescent athletes aged 11-16 years, employing refined Seattle interpretation criteria. Additionally, we seek to compare these findings based on age group and sex. METHODS This was a retrospective and observational study of 3747 athletes 11-16 year-olds. Evaluation included interviewer-administered questionnaires for relevant history, physical examination and resting 12 - lead ECG for each participant. The primary outcome measure was abnormal ECG findings according to the International Recommendations for Electrocardiographic Interpretation in Athletes. RESULTS Among the evaluated population of pediatric and young adolescent athletes (77.5% boys; >99% Caucasian), the vast majority exhibited normal electrocardiogram (ECG) results, with adaptive findings related to sports participation being more frequent among young adolescents and males. The presence of significant ECG abnormalities in young-adolescent athletes was uncommon (2.05%; 1.92% children and 2.32% young-adolescent) and required additional examinations. 0.27% of the total population were diagnosed with a previously unknown cardiac pathology only through the ECG. CONCLUSIONS This study provides valuable insights into the prevalence of normal, borderline, and abnormal electrocardiogram (ECG) findings in a large population of pediatric and young-adolescent athletes. These findings serve as guidance in detecting potentially serious cardiac alterations within this specific group, considering variations based on age and sex. The study confirms that ECG screening is a useful tool for identifying cardiac abnormalities in pediatric and young-adolescent athletes, even though the prevalence of significant findings in this population is relatively low. Furthermore, our findings support the utilization of the refined Seattle criteria as a sensitive and specific technique for screening pediatric and young-adolescent athletes, further enhancing the accuracy of ECG-based evaluations.
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Affiliation(s)
- Uxua Idiazabal-Ayesa
- Servicio de Cardiología y Medicina Interna, Hospital García Orcoyen, Estella, Navarra, Spain; Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Robinson Ramírez-Vélez
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain; CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
| | - María Sanz-de la Garza
- Cardiovascular Institute, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Mikel Izquierdo
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain; CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain.
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Graziano F, Cipriani A, Balla D, Bondarev S, Marra MP, Bauce B, Vágó H, Corrado D, Zorzi A. Evolving spectrum of arrhythmogenic cardiomyopathy: Implications for Sports Cardiology. Clin Cardiol 2023; 46:1072-1081. [PMID: 37357443 PMCID: PMC10540004 DOI: 10.1002/clc.24069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/27/2023] Open
Abstract
Arrhythmogenic cardiomyopathy (ACM) is a genetic heart muscle disease, structurally characterized by progressive fibro-fatty replacement of the normal myocardium and clinically by ventricular arrhythmias (VAs). Predominantly thanks to the use of cardiac magnetic resonance, we have learnt that the spectrum of the disease encompasses not only the classical right ventricular phenotype, but also biventricular and left dominant variants. Sport activity contributes to the phenotypic expression and progression of ACM and may trigger life-threatening VAs and sudden cardiac death (SCD). We conducted a review of the literature about ACM and its implications in Sport Cardiology and summarized the main findings in this topic. Early identification of affected athletes through preparticipation screening (PPS) is fundamental but, while classical right-ventricular or biventricular phenotypes are usually suspected because of electrocardiogram (ECG) and echocardiographic abnormalities, variants with predominant left ventricular involvement are often characterized by normal ECG and unremarkable echocardiography. Usually the only manifestations of such variants are exercise-induced VAs and for this reason exercise testing may empower the diagnostic yield of the PPS. Patients with ACM are not eligible to competitive sports activity, but low-to-moderate intensity physical activity under medical supervision is possible in most cases.
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Affiliation(s)
- Francesca Graziano
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
| | - Dorottya Balla
- Department of Sports MedicineSemmelweis UniversityBudapestHungary
| | - Sergei Bondarev
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
| | - Barbara Bauce
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
| | - Hajnalka Vágó
- Department of Sports MedicineSemmelweis UniversityBudapestHungary
- Heart and Vascular CenterSemmelweis UniversityBudapestHungary
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public HealthUniversity of PaduaPadovaItaly
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10
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Lim B, Lim B, Hamzah F, Lim AT, Ng CS, Tan B, Tong KL. Comparison of four electrocardiographic criteria for the detection of cardiac abnormalities in Singapore athletes. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:230-238. [PMID: 38904520 DOI: 10.47102/annals-acadmedsg.2022191] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
Introduction Sudden cardiac death in athletes is a rare occurrence, the most common cause being hypertrophic cardiomyopathy, which increases the risk of sustained ventricular tachycardia or ventricular fibrillation. Most of these young athletes are asymptomatic prior to the cardiac arrest. Several electrocardiogram criteria such as the European Society of Cardiology group 2 Criteria changes, Seattle Criteria, Refined Criteria, and most recently the 2017 International Criteria, have sought to improve the accuracy of identifying these at-risk athletes during pre-participation screening while minimising unnecessary investigations for the majority of athletes at low risk.We aimed to compare the above four criteria in our Singapore athlete population to identify which criterion performed the best in detecting cardiac abnormalities on echocardiography. Method Out of 1,515 athletes included in Changi General Hospital, Singapore registry between June 2007 and June 2014, the electrocardiograms of 270 athletes with further cardiac investigations were analysed. We compared the above four electrocardiographic criteria to evaluate which performed best for detecting cardiac abnormalities on echocardiography in our Southeast Asian athlete population. Results The European Society of Cardiology, Seattle, Refined and 2017 International Criteria had a sensitivity of 20%, 0%, 20% and 5%, respectively; a specificity of 64%, 93%, 84% and 97%, respectively; a positive predictive value of 4%, 0%, 9% and 11%, respectively; and a negative predictive value of 91%, 92%, 93% and 93%, respectively for detecting abnormalities on echocardiography. Conclusion The latest 2017 International Criteria performed the best as it had the highest specificity and positive predictive value, joint highest negative predictive value, and lowest false positive rate.
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Affiliation(s)
- Benji Lim
- Department of Cardiology, Changi General Hospital, Singapore
| | - Baoying Lim
- Department of Sport and Exercise Medicine, Changi General Hospital, Singapore
| | - Fadzil Hamzah
- Department of Sport and Exercise Medicine, Changi General Hospital, Singapore
| | - Ang Tee Lim
- Department of Sport and Exercise Medicine, Changi General Hospital, Singapore
| | - Chung Sien Ng
- Department of Sport and Exercise Medicine, Changi General Hospital, Singapore
| | - Benedict Tan
- Department of Sport and Exercise Medicine, Changi General Hospital, Singapore
| | - Khim Leng Tong
- Department of Cardiology, Changi General Hospital, Singapore
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11
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Grant A, Krishan S, Chukumerije M, Guseh JS, Kim JH. Reckoning with race in sports cardiology: a call to action. Br J Sports Med 2023:bjsports-2022-106553. [PMID: 37130617 DOI: 10.1136/bjsports-2022-106553] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 05/04/2023]
Affiliation(s)
- Aubrey Grant
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sheela Krishan
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - James Sawalla Guseh
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jonathan H Kim
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Department of Medicine, Atlanta, Georgia, USA
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12
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Ho WHH, Lim DYZ, Thiagarajan N, Wang H, Loo WTW, Sng GGR, Lee JSW, Shen X, Dalakoti M, Sia C, Tan BYQ, Lim HY, Wang L, Chow W, Chua TSJ, Lim PCY, Yeo TJ, Chong DTT. Outcomes of Investigating T Wave Inversion With Echocardiography in an Unselected Young Male Preparticipation Cohort. J Am Heart Assoc 2023; 12:e026975. [PMID: 36942750 PMCID: PMC10122903 DOI: 10.1161/jaha.122.026975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 12/19/2022] [Indexed: 03/23/2023]
Abstract
BACKGROUND Electrocardiography (ECG) may be performed as part of preparticipation sports screening. Recommendations on screening of athletes to identify individuals with previously unrecognized cardiac disease are robust; however, data guiding the preparticipation screening of unselected populations are scarce. T wave inversion (TWI) on ECG may suggest an undiagnosed cardiomyopathy. This study aims to describe the prevalence of abnormal TWI in an unselected young male cohort and the outcomes of an echocardiography-guided approach to investigating these individuals for structural heart diseases, focusing on the yield for cardiomyopathies. METHODS AND RESULTS Consecutive young male individuals undergoing a national preparticipation cardiac screening program for 39 months were studied. All underwent resting supine 12-lead ECG. Those manifesting abnormal TWI, defined as negatively deflected T waves of at least 0.1 mV amplitude in any 2 contiguous leads, underwent echocardiography. A total of 69 714 male individuals with a mean age of 17.9±1.1 years were studied. Of the individuals, 562 (0.8%) displayed abnormal TWI. This was most frequently observed in the anterior territory and least so in the lateral territory. A total of 12 individuals (2.1%) were diagnosed with a cardiomyopathy. Cardiomyopathy diagnoses were significantly associated with deeper maximum TWI depth and the presence of abnormal TWI in the lateral territory, but not with abnormal TWI in the anterior and inferior territories. No individual presenting with TWI restricted to solely leads V1 to V2, 2 inferior leads or both was diagnosed with a cardiomyopathy. CONCLUSIONS Cardiomyopathy diagnoses were more strongly associated with certain patterns of abnormal TWI. Our findings may support decisions to prioritize echocardiography in these individuals.
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Affiliation(s)
- Wilbert H. H. Ho
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Daniel Y. Z. Lim
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Nishanth Thiagarajan
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Hankun Wang
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Wesley T. W. Loo
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Gerald G. R. Sng
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Joshua S. W. Lee
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Xiayan Shen
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of CardiologyNational Heart Centre SingaporeSingaporeSingapore
| | - Mayank Dalakoti
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of CardiologyNational University Heart Centre SingaporeSingaporeSingapore
- Department of MedicineYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
| | - Ching‐Hui Sia
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of CardiologyNational University Heart Centre SingaporeSingaporeSingapore
- Department of MedicineYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
| | - Benjamin Y. Q. Tan
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of MedicineYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
- University Medicine ClusterNational University Health SystemSingaporeSingapore
| | - Huai Yang Lim
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
| | - Luo‐Kai Wang
- HQ Medical Corps, Singapore Armed ForcesSingaporeSingapore
| | - Weien Chow
- Department of CardiologyChangi General HospitalSingaporeSingapore
| | | | - Paul C. Y. Lim
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of CardiologyNational Heart Centre SingaporeSingaporeSingapore
| | - Tee Joo Yeo
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of CardiologyNational University Heart Centre SingaporeSingaporeSingapore
- Department of MedicineYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
| | - Daniel T. T. Chong
- Medical Classification CentreCentral Manpower Base, Singapore Armed ForcesSingaporeSingapore
- Department of CardiologyNational Heart Centre SingaporeSingaporeSingapore
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Petek BJ, Drezner JA, Churchill TW. The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions. Cardiol Clin 2023; 41:35-49. [PMID: 36368810 PMCID: PMC10292923 DOI: 10.1016/j.ccl.2022.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan A Drezner
- University of Washington Medical Center for Sports Cardiology, Massachusetts General Hospital, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA 98195, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA.
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14
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The Impact of Ethnicity on Athlete ECG Interpretation: A Systematic Review. J Cardiovasc Dev Dis 2022; 9:jcdd9060183. [PMID: 35735812 PMCID: PMC9225578 DOI: 10.3390/jcdd9060183] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/04/2022] [Accepted: 06/06/2022] [Indexed: 11/30/2022] Open
Abstract
Athlete ECG interpretation criteria have been developed and refined from research in athlete populations; however, current guidelines are based on available data primarily from Caucasian and Black athletes. This study aimed to assess the impact of ethnicity on ECG interpretation in athletes. A systematic review was conducted of the MEDLINE, EMBASE, Scopus, SPORTDiscus, and Web of Science databases, for papers that assessed athlete screening ECGs and compared findings on the basis of ethnicity. Fifty-one papers which compared ECGs from various ethnicities were included. Most studies assessed Black athletes against Caucasian athletes and found a greater prevalence of T-wave inversion (TWI) (2.6–22.8% vs. 0–5.0%) and anterior TWI (3.7–14.3% vs. 0.6–2.0%). Black athlete subgroups in Africa had TWI (20–40%) and anterior TWI (4.3–18.7%) at a higher prevalence than other Black athletes. Athletes who were defined as mixed-race, Asian, and Pacific Islander are potentially more like Black athletes than Caucasian athletes. Black ethnicity is known to have an impact on the accurate interpretation of athlete ECGs; however, there is nuance related to origin of both parents. Asian and Pacific Islander origin also may impact athlete ECG interpretation. Further research is required to assist in distinguishing abnormal and normal athlete ECGs in different ethnic populations.
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15
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Patel VI, Gradus-Pizlo I, Malik S, Barseghian El-Farra A, Dineen EH. Cardiodiagnostic sex-specific differences of the female athlete in sports cardiology. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 17:100149. [PMID: 38559879 PMCID: PMC10978368 DOI: 10.1016/j.ahjo.2022.100149] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 04/04/2024]
Abstract
The cardiovascular care of highly active individuals and competitive athletes has developed into an important focus within the field of sports medicine. An evolving understanding of exercise-induced cardiovascular remodeling in athletes has led to a more robust characterization of physiologic adaptation versus pathological dysfunction, but this distinction is often challenging due to diagnostic commonalities. Current data reflects sporting-focused analyses of mainly male athletes, which may not be easily applicable to the female athletic heart. Increasingly female-specific cardiac dimensional and physiologic data are starting to emerge from comparative studies that may be utilized to address this growing need, and further guide individualized care. Here, we review current literature evaluating female-specific cardiovascular adaptations of the athletic heart, and formulate a discussion on cardiac remodeling, cardiodiagnostic findings, etiologic mechanisms, limitations of currently available data, and direction for future research in the cardiovascular care of female athletes.
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Affiliation(s)
- Vishal I. Patel
- Corresponding author at: Division of Cardiology, Department of Internal Medicine, University of California, Irvine, School of Medicine, 101 The City Drive South, Building 200, Room 414, Orange, CA 92868, United States of America.
| | - Irmina Gradus-Pizlo
- Division of Cardiology, University of California, Irvine, School of Medicine, Orange, CA 92868, United States of America
- Susan Samueli Integrative Health Institute, UCI Health, Orange, CA 92868, United States of America
| | - Shaista Malik
- Division of Cardiology, University of California, Irvine, School of Medicine, Orange, CA 92868, United States of America
- Susan Samueli Integrative Health Institute, UCI Health, Orange, CA 92868, United States of America
| | - Ailin Barseghian El-Farra
- Division of Cardiology, University of California, Irvine, School of Medicine, Orange, CA 92868, United States of America
- Susan Samueli Integrative Health Institute, UCI Health, Orange, CA 92868, United States of America
| | - Elizabeth H. Dineen
- Division of Cardiology, University of California, Irvine, School of Medicine, Orange, CA 92868, United States of America
- Susan Samueli Integrative Health Institute, UCI Health, Orange, CA 92868, United States of America
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16
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Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Clin Electrophysiol 2022; 8:533-553. [PMID: 35450611 DOI: 10.1016/j.jacep.2021.12.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 01/21/2023]
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) encompasses a group of conditions characterized by right ventricular fibrofatty infiltration, with a predominant arrhythmic presentation. First described in the late 1970s and early 1980s, it is now frequently recognized to have biventricular involvement. The prevalence is ∼1:2,000 to 1:5,000, depending on geographic location, and it has a slight male predominance. The diagnosis of ARVC is determined on the basis of fulfillment of task force criteria incorporating electrophysiological parameters, cardiac imaging findings, genetic factors, and histopathologic features. Risk stratification of patients with ARVC aims to identify those who are at increased risk of sudden cardiac death or sustained ventricular tachycardia. Factors including age, sex, electrophysiological features, and cardiac imaging investigations all contribute to risk stratification. The current management of ARVC includes exercise restriction, β-blocker therapy, consideration for implantable cardioverter-defibrillator insertion, and catheter ablation. This review summarizes our current understanding of ARVC and provides clinicians with a practical approach to diagnosis and management.
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17
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Molitor N, Duru F. Arrhythmogenic Right Ventricular Cardiomyopathy and Differential Diagnosis with Diseases Mimicking Its Phenotypes. J Clin Med 2022; 11:jcm11051230. [PMID: 35268321 PMCID: PMC8911116 DOI: 10.3390/jcm11051230] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 12/13/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited heart muscle disease, which is characterized by fibro-fatty replacement of predominantly the right ventricle (RV). The disease can result in ventricular tachyarrhythmias and sudden cardiac death. Our understanding of the pathophysiology and clinical expressivity of ARVC has been continuously evolving. The diagnosis can be challenging due to its variable expressivity, incomplete penetrance and the lack of specific diagnostic criteria. Idiopathic RV outflow tract tachycardia, Brugada Syndrome, athlete’s heart, dilated cardiomyopathy, myocarditis, cardiac sarcoidosis, congenital aneurysms and diverticula may mimic clinical phenotypes of ARVC. This review aims to provide an update on the differential diagnosis of ARVC.
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Affiliation(s)
- Nadine Molitor
- Division of Arrhythmias and Electrophysiology, Clinic for Cardiology, University Heart Center Zurich, 8091 Zurich, Switzerland;
| | - Firat Duru
- Division of Arrhythmias and Electrophysiology, Clinic for Cardiology, University Heart Center Zurich, 8091 Zurich, Switzerland;
- Center for Integrative Human Physiology, University of Zurich, 8057 Zurich, Switzerland
- Correspondence: ; Tel.: +41-44-2553565
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18
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Allwood RP. Differentiating right ventricular remodelling from cardiac pathology in athletes. SONOGRAPHY 2022. [DOI: 10.1002/sono.12299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Richard P. Allwood
- Cardiology Department St Vincent's Hospital Melbourne Melbourne Victoria Australia
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19
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Pambo P, Adu-Adadey M, Agbodzakey H, Scharhag J. Electrocardiographic and Echocardiographic Findings in Elite Ghanaian Male Soccer Players. Clin J Sport Med 2021; 31:e373-e379. [PMID: 31876793 DOI: 10.1097/jsm.0000000000000801] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 10/22/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To analyze the athlete's heart of adult and adolescent elite male soccer players by electrocardiography (ECG) and echocardiography (ECHO) and to describe typical ECG and ECHO findings in this cohort (West African elite soccer players). DESIGN A cross-sectional study of ECGs and ECHOs conducted as part of precompetition medical assessment for national male soccer teams preparing for various Fédération Internationale de Football Association (FIFA) tournaments in 2016 and 2017. SETTING Ghana National Football Association. PARTICIPANTS One hundred fifty-nine players playing for the National male soccer teams preparing for tournaments in 2016 and 2017. INTERVENTIONS Precompetition medical assessment using ECGs and ECHOs. MAIN OUTCOME MEASURES Number of athletes with abnormal ECGs and ECHO findings. RESULTS Twenty-three percent of the players had abnormal ECGs. Nine percent of the participants had T-wave inversions in lateral leads (V5-V6). Sokolow-Lyon criteria for left ventricular hypertrophy were present in 64% of participants. Thirty-six (23%) players had left ventricular wall thickness (LVWT) ≥13 mm, with no player exceeding 16 mm. Four percent of players had left ventricular cavity dimension greater than 60 mm. Relative wall thickness >0.42 was present in 44% of the players. CONCLUSIONS Uncommon ECG changes seem to be more common in elite Ghanaian soccer players compared with previously reported results for Caucasians and even mixed populations of black athletes. Although ST elevation, T-wave inversions, and LVWT up to 15 mm are common, ST depression, deep T-waves in lateral leads, and LVWT ≥16 mm always warrant further clinical and scientific investigations.
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Affiliation(s)
- Prince Pambo
- University of Health and Allied Sciences, Ho, Ghana
- Civil Service/Stadium Clinic, School of Allied Sciences, Ghana Health Service
- Sports Medicine Department, Institute for Sports and Preventive Medicine, Saarland University, Saarbrucken, Germany
| | - Martin Adu-Adadey
- National Cardiothoracic Centre, Korle-Bu Teaching Hospital, Accra, Ghana ; and
| | - Hope Agbodzakey
- Civil Service/Stadium Clinic, School of Allied Sciences, Ghana Health Service
| | - Jürgen Scharhag
- Sports Medicine Department, Institute for Sports and Preventive Medicine, Saarland University, Saarbrucken, Germany
- Department of Sports Medicine, Exercise Physiology and Prevention, University of Vienna, Vienna, Austria
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20
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Gossios T, Savvatis K, Zegkos T, Ntelios D, Rouskas P, Parcharidou D, Karvounis H, Efthimiadis GK. Deciphering hypertrophic cardiomyopathy with electrocardiography. Heart Fail Rev 2021; 27:1313-1323. [PMID: 34286451 DOI: 10.1007/s10741-021-10147-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2021] [Indexed: 11/30/2022]
Abstract
The comprehensive assessment of patients with hypertrophic cardiomyopathy is a complex process, with each step concurrently focusing on confirmation of the diagnosis, differentiation between sarcomeric and non-sarcomeric disease (phenocopy), and prognostication. Novel modalities such as genetic testing and advanced imaging have allowed for substantial advancements in the understanding of this condition and facilitate patient management. However, their availability is at present not universal, and interpretation requires a high level of expertise. In this setting, electrocardiography, a fast and widely available method, still retains a significant role in everyday clinical assessment of this population. In our review, we follow a stepwise approach for the interpretation of each electrocardiographic segment, discussing clinical implications of electrocardiographic patterns in sarcomeric disease, their value in the differential diagnosis from phenocopies, and impact on patient management. Outlining the substantial amount of information to be obtained from a simple tracing, we exhibit how electrocardiography is likely to remain an integral diagnostic tool in the future as well.
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Affiliation(s)
- Thomas Gossios
- Cardiology Department, NHS Foundation Trust, Guy's and St Thomas Westminster Bridge Road, London, SE1 7EH, UK. .,Inherited Cardiac Conditions Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK. .,Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece.
| | - Konstantinos Savvatis
- Inherited Cardiac Conditions Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Thomas Zegkos
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Dimitrios Ntelios
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Pavlos Rouskas
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Despoina Parcharidou
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Haralambos Karvounis
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Georgios K Efthimiadis
- Cardiomyopathies Laboratory, 1st Aristotle University of Thessaloniki Cardiology Department, AHEPA University Hospital, Thessaloniki, Greece
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21
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Gasperetti A, James CA, Cerrone M, Delmar M, Calkins H, Duru F. Arrhythmogenic right ventricular cardiomyopathy and sports activity: from molecular pathways in diseased hearts to new insights into the athletic heart mimicry. Eur Heart J 2021; 42:1231-1243. [PMID: 33200174 DOI: 10.1093/eurheartj/ehaa821] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/12/2020] [Accepted: 09/24/2020] [Indexed: 12/14/2022] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited disease associated with a high risk of sudden cardiac death. Among other factors, physical exercise has been clearly identified as a strong determinant of phenotypic expression of the disease, arrhythmia risk, and disease progression. Because of this, current guidelines advise that individuals with ARVC should not participate in competitive or frequent high-intensity endurance exercise. Exercise-induced electrical and morphological para-physiological remodelling (the so-called 'athlete's heart') may mimic several of the classic features of ARVC. Therefore, the current International Task Force Criteria for disease diagnosis may not perform as well in athletes. Clear adjudication between the two conditions is often a real challenge, with false positives, that may lead to unnecessary treatments, and false negatives, which may leave patients unprotected, both of which are equally inacceptable. This review aims to summarize the molecular interactions caused by physical activity in inducing cardiac structural alterations, and the impact of sports on arrhythmia occurrence and other clinical consequences in patients with ARVC, and help the physicians in setting the two conditions apart.
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Affiliation(s)
- Alessio Gasperetti
- Division of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Cynthia A James
- Division of Cardiology, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Marina Cerrone
- Leon H Charney Division of Cardiology, New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Mario Delmar
- Leon H Charney Division of Cardiology, New York University School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Firat Duru
- Division of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland.,Center for Integrative Human Physiology, University of Zurich, Rämistrasse 71, Zurich 8006, Switzerland
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22
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Landry CH, Fatah M, Connelly KA, Angaran P, Hamilton RM, Dorian P. Evaluating the 12-Lead Electrocardiogram for Diagnosing ARVC in Young Populations: Implications for Preparticipation Screening of Athletes. CJC Open 2021; 3:498-503. [PMID: 34027353 PMCID: PMC8129442 DOI: 10.1016/j.cjco.2020.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 10/24/2022] Open
Abstract
Background Arrhythmogenic right-ventricular cardiomyopathy (ARVC) is an identified cause of sport-related sudden cardiac arrest (SCA). Identifying athletes with ARVC and restricting them from exercise is believed to reduce the risk of SCA. The electrocardiogram (ECG) is considered to be an important component of screening for ARVC; however, the sensitivity of the 12-lead ECG to identify ARVC in young asymptomatic persons is unknown. Methods In this retrospective study, we identified 70 patients (49 ARVC-positive, based on Task Force Criteria, and 21 age-matched ARVC-negative persons from a paediatric arrhythmia database (<18 years of age); ECGs were analyzed for abnormalities, based on International Criteria for Interpretation of ECGs in Athletes, and ECG findings were adjudicated by group consensus. Results Of the 49 ARVC-positive patients (median age: 17 [interquartile range: 16-18], 65% male), 22% were found to have abnormal ECGs; the most common ECG findings were T-wave inversions. Patients with symptoms were more likely to have abnormal ECGs than asymptomatic patients (28% compared with 17%, respectively; P = 0.002). Of 16 gene-positive patients, 31% had abnormal ECGs. Patients with abnormal ECGs had larger right-ventricular end-diastolic volume indexes on magnetic resonance imaging than those with normal ECGs (P = 0.03). Conclusions The ECG was insensitive for detecting ARVC in young (age <18 years), asymptomatic patients, and is unlikely to provide significant diagnostic value for identifying ARVC on routine preparticipation screening of adolescent athletes.
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Affiliation(s)
- Cameron H Landry
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Meena Fatah
- Department of Paediatrics (Cardiology) and the Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kim A Connelly
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute and the Keenan Research Centre, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Paul Angaran
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Robert M Hamilton
- Department of Paediatrics (Cardiology) and the Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Dorian
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
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23
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Cardiac magnetic resonance in patients with ARVC and family members: the potential role of native T1 mapping. Int J Cardiovasc Imaging 2021; 37:2037-2047. [PMID: 33550486 PMCID: PMC8255264 DOI: 10.1007/s10554-021-02166-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 01/16/2021] [Indexed: 02/07/2023]
Abstract
Left ventricular (LV) involvement in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) is not evaluated in the revised Task Force Criteria, possibly leading to underdiagnosis. This study explored the diagnostic role of myocardial native T1 mapping in patients with ARVC and their first-degree relatives. Thirty ARVC patients (47% males, mean age 45 ± 27 years) and 59 first-degree relatives not meeting diagnostic criteria underwent CMR with native T1 mapping. C MR was abnormal in 26 (87%) patients with ARVC. The right ventricle was affected in isolation in 13 (43%) patients. Prior to T1 mapping assessment, 2 (7%) patients exhibited isolated LV involvement and 11 (36%) patients showed features of biventricular disease. Left ventricular involvement was manifest as detectable LV late gadolinium enhancement (LGE) in 12 out of 13 cases. According to pre-specified inter-ventricular septal (IVS) T1 mapping thresholds, 11 (37%) patients revealed raised native T1 values including 5 out of the 17 patients who would otherwise have been classified as exhibiting a normal LV by conventional imaging parameters. Native septal T1 values were elevated in 22 (37%) of the 59 first-degree relatives included. Biventricular involvement is commonly observed in ARVC; native myocardial T1 values are raised in more than one third of patients, including a significant proportion of cases that would have been otherwise classified as exhibiting a normal LV using conventional CMR techniques. The significance of abnormal T1 values in first-degree relatives at risk will need validation through longitudinal studies.
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24
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Fabre JB, Grelot L, Vanbiervielt W, Mazerie J, Manca R, Martin V. Managing the combined consequences of COVID-19 infection and lock-down policies on athletes: narrative review and guidelines proposal for a safe return to sport. BMJ Open Sport Exerc Med 2020; 6:e000849. [PMID: 33194223 PMCID: PMC7610250 DOI: 10.1136/bmjsem-2020-000849] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/04/2020] [Accepted: 10/03/2020] [Indexed: 01/08/2023] Open
Abstract
COVID-19 pandemic is a global health matter. The disease spread rapidly across the globe and brought the world of sports to an unprecedented stoppage. Usual symptoms of the disease are fever, cough, myalgia, fatigue, slight dyspnoea, sore throat and headache. In more severe cases, dyspnoea, hypoxaemia, respiratory failure, shock and multiorgan failure occur. This appears to be a self-limiting phenomenon related to individuals with coexisting medical conditions, such as hypertension, diabetes and cardiovascular disorders. Nevertheless, cases have been reported in professional soccer players in extremely good fitness condition, demonstrating that athletes are not spared by the disease. Despite COVID-19 clinical manifestations are mainly respiratory, major cardiac complications are being reported, leading to acute myocarditis. One difficulty is that symptoms of COVID-19 vary among individuals, with athletes being affected with no apparent sign of the disease. This could be a real danger for amateur or professional athletes when returning to their usual training and thus to play. Another threat is that the lock-down policies did not allow most athletes to follow their usual training routines. There is thus a need for a careful approach by the sports medicine community to ensure safety of all athletes before they return to sport. Here, we propose evaluation guidelines of fitness and health of athletes to (1) reduce any lethal risk of practice, especially myocarditis and sudden cardiac death; (2) evaluate the combined consequences of the disease and detraining on the physical abilities and biological profile of athletes; and (3) monitor postinfection fatigue symptoms.
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Affiliation(s)
| | - Laurent Grelot
- Health and Safety Department, Aix-Marseille-University,Marseille, France
| | | | | | - Raphael Manca
- Institut Universitaire de France (IUF), Paris, France
| | - Vincent Martin
- Université Clermont Auvergne, AME2P, Clermont-Ferrand,France
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25
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Abela M, Sharma S. Electrocardiographic interpretation in athletes. Minerva Cardiol Angiol 2020; 69:533-556. [PMID: 33059398 DOI: 10.23736/s2724-5683.20.05331-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Participation in regular exercise of moderate intensity is associated with a plethora of systemic benefits, including a reduction in risk factors for coronary atherosclerosis; however, intensive exercise may paradoxically culminate in sudden cardiac arrest among individuals harboring arrhythmogenic substrates. The precise mechanism for arrhythmogenesis is likely multifactorial, however, surges in catecholamines, electrolyte shifts, acid-base disturbances, increased core temperature and demand myocardial ischemia are potential contributors. Although most deaths occur in middle aged and older males with atherosclerotic coronary artery disease, a significant proportion also affect young athletes with inherited or congenital cardiac abnormalities. The impact of such catastrophes on society, particularly when a young high-profile athlete is affected could be considered a justified reason for identifying individuals who may be at risk. Given the rarity of deaths in young athletes, only the simplest screening test, such as the 12-lead electrocardiography (ECG) may be considered to be cost effective. The ECG is effective for detecting serious electrical diseases in young athletes such as congenital electrical accessory pathways and ion channel diseases but can also identify athletes with potential life-threatening structural diseases such as hypertrophic and arrhythmogenic cardiomyopathy. One of the concerns about ECG screening is that regular intensive exercise results in several physiological alterations in cardiac structure and function that are reflected on the athlete's ECG. Sinus bradycardia, first-degree atrioventricular block, incomplete right bundle branch block, minor J-point elevation and large QRS voltages are common. Conversely, some repolarization anomalies affecting the ST segment, T waves and QT interval may overlap with patterns observed in patients with serious cardiac diseases. The situation is complicated further because age, sex and ethnicity of the athletes also influence the ECG and there is a risk that erroneous interpretation could have serious consequences. This review will describe the normal electrical patterns of the "athlete's heart" and provide insights into differentiation physiological electrical patterns from those observed in serious cardiac disease.
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Affiliation(s)
- Mark Abela
- Department of Cardiology, Mater Dei Hospital, Msida, Malta - .,Malta Medical School, University of Malta, Msida, Malta - .,St. George's University Hospitals, NHS Foundation Trust, St George's University, London, UK -
| | - Sanjay Sharma
- St. George's University Hospitals, NHS Foundation Trust, St George's University, London, UK
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26
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Arshad S, Ferrick NJ, Monrad ES, Fisher JD, Krumerman A, Ferrick KJ. Prevalence and association of the Wellens' sign with coronary artery disease in an ethnically diverse urban population. J Electrocardiol 2020; 62:211-215. [PMID: 32992259 DOI: 10.1016/j.jelectrocard.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/30/2020] [Accepted: 09/02/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Wellens' sign is considered to be an ominous sign indicative of underlying significant proximal left anterior descending artery stenosis. We sought to identify the prevalence of the Wellens' pattern in a large ethnically diverse urban population and assess its association with the presence and extent of coronary artery disease. METHODS We utilized the MUSE ECG database of Montefiore Medical Center, an academic tertiary health care system, to identify ECGs from 2012 to 2019 exhibiting a Wellens' pattern. From a dataset of 1.76 million tracings, six screening diagnosis codes were selected to approximate the Wellens' pattern. These codes were used to generate a cohort of ECGs for manual review by a board certified cardiologist to determine if a Wellens' pattern was present. RESULTS Of 1,756,742 ECGs performed on 433,218 patients from 2012 to 2019; after initial screening 2186 ECGs were identified for manual review. Of these, 448 (0.1%) patients were confirmed to have a Wellens' pattern. 229 patients underwent cardiac catheterization, while 219 patients were managed medically. No statistical difference was seen in the occurrence of Wellens' Type A and B pattern across the ethnic groups after multivariate analysis. Women were more likely to have Type B Wellens' compared to men (OR 2.40 (1.58, 3.62) P < 0.0001). 80 (35%) patients had single vessel LAD disease of which 22 (10%) had proximal, 40 (17%) had mid, 4 (1%) had distal stenosis, while diffuse LAD disease was seen in 14 (6%) patients. Two vessel disease was seen in 46 (20%) patients with a Wellens' pattern, and triple vessel disease was seen in 23 (10%) patients. Of note, 71 (31%) patients had either normal or nonobstructive coronary disease despite exhibiting a Wellens' pattern ECG. CONCLUSION Wellens' sign is a rare electrocardiographic pattern which when seen in a patient with an appropriate clinical presentation, suggests but is not definitive for the presence of significant coronary disease, often but not exclusively in an LAD distribution. We found no statistical difference in the occurrence of Wellens' sign among different racial/ethnic groups. Patients with a Wellens' pattern may have critical lesions at a variety of LAD sites as well as in multiple vessels. As such, the interventionalist needs to be prepared for these uncertainties at the time of cardiac catheterization.
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Affiliation(s)
- Samiullah Arshad
- Montefiore Medical Center- Wakefield Campus, Department of Internal Medicine, 600 East 233(rd) Street, Bronx, New York 10466, USA.
| | - Neal J Ferrick
- Montefiore Medical Center, Department of Internal Medicine, 111 East 210 Street, Bronx, New York 10467, USA.
| | - E Scott Monrad
- Montefiore- Einstein Center for Heart and Vascular Care, Division of Cardiology, 111 East 210 Street, Bronx, New York 10467, USA.
| | - John D Fisher
- Montefiore- Einstein Center for Heart and Vascular Care, Division of Cardiology, 111 East 210 Street, Bronx, New York 10467, USA.
| | - Andrew Krumerman
- Montefiore- Einstein Center for Heart and Vascular Care, Division of Cardiology, 111 East 210 Street, Bronx, New York 10467, USA.
| | - Kevin J Ferrick
- Montefiore- Einstein Center for Heart and Vascular Care, Division of Cardiology, 111 East 210 Street, Bronx, New York 10467, USA.
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27
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Imamura T, Sumitomo N, Muraji S, Yasuda K, Nishihara E, Iwamoto M, Tateno S, Doi S, Hata T, Kogaki S, Horigome H, Ohno S, Ichida F, Nagashima M, Makiyama T, Yoshinaga M. Impact of the T-wave characteristics on distinguishing arrhythmogenic right ventricular cardiomyopathy from healthy children. Int J Cardiol 2020; 323:168-174. [PMID: 32877757 DOI: 10.1016/j.ijcard.2020.08.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/03/2020] [Accepted: 08/26/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND T-wave inversion (TWI) is not considered useful for diagnosing pediatric arrhythmogenic right ventricular cardiomyopathy (ARVC), because right precordial TWI in ARVC resembles a normal juvenile pattern. OBJECTIVES The aims of this study were to clarify the electrocardiographic (ECG) characteristics of pediatric ARVC to distinguish those patients from healthy children. METHODS Between 1979 and 2017, 11 ARVC patients under 18 years old were registered and compared with school screening ECGs from 48,401 healthy children. RESULTS The mean age at the first arrhythmic event or diagnosis was 13.3 ± 4.7 years. Nine patients were asymptomatic initially and were found by ECG screening, but 6 developed severe symptoms during the follow-up. Healthy children had a normal juvenile pattern, while ARVC children, especially symptomatic patients, had a significant tendency to have inferior and anterior TWI. The phenomenon of T-wave discontinuity (TWD) in which the TWI became deeper from V1 to V3 and suddenly turned positive in V5 was significantly more frequent in ARVC (60%) than healthy children (0.55%). Anterior TWI and TWD were also significantly more frequent in those who developed severe symptoms. The sensitivity and specificity of TWD were 60% (95% CI, 31-83%), and 99% (95% CI, 99-99%) to distinguish ARVC from healthy children, as well as 100% (95% CI, 71-100%) and 80% (95% CI, 51-80%), respectively, to predict severe symptoms in the future. CONCLUSIONS The ECG is useful to distinguish ARVC children, even in the early phase. Anterior TWI and TWD could detect ARVC children and to predict the possible serious conditions.
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Affiliation(s)
- Tomohiko Imamura
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama, Japan; Department of Cardiology, Kyoto University, Kyoto, Japan
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama, Japan.
| | - Shota Muraji
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Kazushi Yasuda
- Department of Pediatric Cardiology, Aichi Children's Health and Medical Center, Aichi, Japan
| | - Eiki Nishihara
- Department of Cardiology, Ogaki Municipal Hospital, Gifu, Japan
| | - Mari Iwamoto
- Department of Pediatrics, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
| | - Shigeru Tateno
- Department of Pediatrics, Chiba Kaihin Municipal Hospital, Chiba, Japan
| | - Shozaburo Doi
- National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Tadayoshi Hata
- Department of Pediatrics, Fujita Health University, Aichi, Japan
| | - Shigetoyo Kogaki
- Department of Pediatrics, Osaka General Medical Center, Osaka, Japan
| | - Hitoshi Horigome
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Seiko Ohno
- Department of Bioscience and Genetics, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Fukiko Ichida
- Department of Pediatrics, International University of Health and Welfare, Tokyo, Japan
| | | | | | - Masao Yoshinaga
- Department of Pediatrics, Kagoshima Medical Center, Kagoshima, Japan
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28
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Ozo U, Sharma S. The Impact of Ethnicity on Cardiac Adaptation. Eur Cardiol 2020; 15:e61. [PMID: 32944090 DOI: 10.15420/ecr.2020.01] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/22/2020] [Indexed: 01/15/2023] Open
Abstract
Regular intensive exercise is associated with a plethora of electrical, structural and functional adaptations within the heart to promote a prolonged and sustained increase in cardiac output. Bradycardia, increased cardiac dimensions, enhanced ventricular filling, augmentation of stroke volume and high peak oxygen consumption are recognised features of the athlete's heart. The type and magnitude of these adaptations to physical exercise are governed by age, sex, ethnicity, sporting discipline and intensity of sport. Some athletes, particularly those of African or Afro-Caribbean (black) origin reveal changes that overlap with diseases implicated in sudden cardiac death. In such instances, erroneous interpretation has potentially serious consequences ranging from unfair disqualification to false reassurance. This article focuses on ethnic variation in the physiological cardiac adaption to exercise.
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29
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Gasperetti A, Dello Russo A, Busana M, Dessanai M, Pizzamiglio F, Saguner AM, te Riele AS, Sommariva E, Vettor G, Bosman L, Duru F, Zeppilli P, Di Biase L, Natale A, Tondo C, Casella M. Novel risk calculator performance in athletes with arrhythmogenic right ventricular cardiomyopathy. Heart Rhythm 2020; 17:1251-1259. [DOI: 10.1016/j.hrthm.2020.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 03/06/2020] [Indexed: 12/17/2022]
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30
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Zorzi A, Vio R, Bettella N, Corrado D. Criteria for interpretation of the athlete's ECG: A critical appraisal. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:882-890. [PMID: 32602144 DOI: 10.1111/pace.14001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/18/2020] [Accepted: 06/28/2020] [Indexed: 01/27/2023]
Abstract
The electrocardiogram (ECG) is cheap and widely available but its use as a screening tool for early identification of athletes with a cardiac disease at risk of sudden cardiac death is controversial because of presumed low specificity. In the last decade, several efforts have been made to improve the distinction between physiological and pathological ECG findings in the athlete, leading to continuous evolution of the interpretation criteria. The most recent 2017 International criteria grouped ECG changes into three categories: normal, borderline, and abnormal. Borderline findings warrant further investigations only when two or more are present while abnormal changes should always be considered as the sign of a possible underlying disease. This review encompasses the evolution of the athlete's ECG interpretation criteria and highlights areas of uncertainty that will need to be addressed by further studies.
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Affiliation(s)
- Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Riccardo Vio
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Natascia Bettella
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
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31
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Differentiating Athlete's Heart from Left Ventricle Cardiomyopathies. J Cardiovasc Transl Res 2020; 13:265-273. [PMID: 32410209 DOI: 10.1007/s12265-020-10021-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 04/28/2020] [Indexed: 01/05/2023]
Abstract
Imaging techniques have allowed knowing the structural adaptative changes observed in the hearts of highly trained athletes. Athletes can develop very marked structural changes and the need may rise for a differential diagnosis with real cardiomyopathy. In this chapter, authors review the physiologic and morphologic features associated with athletic training and the keys to differentiate normal adaptive athlete's heart from mild or initial expression forms of left-heart side cardiomyopathies such as hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), and left ventricle non-compaction (LVNC).
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32
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Arrhythmogenic Cardiomyopathy and Sports Activity. J Cardiovasc Transl Res 2020; 13:274-283. [DOI: 10.1007/s12265-020-09995-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/23/2020] [Indexed: 01/01/2023]
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33
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Myocarditis in the Athlete: Arrhythmogenic Substrates, Clinical Manifestations, Management, and Eligibility Decisions. J Cardiovasc Transl Res 2020; 13:284-295. [PMID: 32270467 DOI: 10.1007/s12265-020-09996-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 03/24/2020] [Indexed: 12/26/2022]
Abstract
Myocarditis is as an important cause of sudden cardiac death (SCD) among athletes. The incidence of SCD ascribed to myocarditis did not change after the introduction of pre-participation screening in Italy, due to the transient nature of the disease and problems in the differential diagnosis with the athlete's heart. The arrhythmic burden and the underlying mechanisms differ between the acute and chronic setting, depending on the relative impact of acute inflammation versus post-inflammatory myocardial fibrosis. In the acute phase, ventricular arrhythmias vary from isolated ventricular ectopic beats to complex tachycardias that can lead to SCD. Atrioventricular blocks are typical of specific forms of myocarditis, and supraventricular arrhythmias may be observed in case of atrial inflammation. Athletes with acute myocarditis should be temporarily restricted from physical exercise, until complete recovery. However, ventricular tachycardia may also occur in the chronic phase in the context of post-inflammatory myocardial scar.
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34
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D'Ascenzi F, Anselmi F, Adami PE, Pelliccia A. Interpretation of T-wave inversion in physiological and pathological conditions: Current state and future perspectives. Clin Cardiol 2020; 43:827-833. [PMID: 32259342 PMCID: PMC7403675 DOI: 10.1002/clc.23365] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 03/16/2020] [Accepted: 03/24/2020] [Indexed: 12/20/2022] Open
Abstract
The presence of T‐wave inversion (TWI) at 12‐lead electrocardiogram (ECG) in competitive athletes is one of the major diagnostic challenges for sports physicians and consulting cardiologists. Indeed, while the presence of TWI may be associated with some benign conditions and it may be occasionally seen in healthy athletes presenting signs of cardiac remodeling, it may also represent an early sign of an underlying, concealed structural heart disease or life‐threatening arrhythmogenic cardiomyopathies, which may be responsible for exercise‐related sudden cardiac death (SCD). The interpretation of TWI in athletes is complex and the inherent implications for the clinical practice represent a conundrum for physicians. Accordingly, the detection of TWI should be viewed as a potential red flag on the ECG of young and apparently healthy athletes and warrants further investigations because it may represent the initial expression of cardiomyopathies that may not be evident until many years later and that may ultimately be associated with adverse outcomes. The aim of this review is, therefore, to report an update of the literature on TWI in athletes, with a specific focus on the interpretation and management.
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Affiliation(s)
- Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesca Anselmi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Paolo Emilio Adami
- Health and Science Department, World Athletics, Monaco, Monaco.,Department of Exercise, Human and Health Sciences, Foro Italico University of Rome, Rome, Italy
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35
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Abela M, Sharma S. Abnormal ECG Findings in Athletes: Clinical Evaluation and Considerations. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:95. [PMID: 31865466 DOI: 10.1007/s11936-019-0794-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Pre-participation cardiovascular evaluation with electrocardiography is normal practice for most sporting bodies. Awareness about sudden cardiac death in athletes and recognizing how screening can help identify vulnerable athletes have empowered different sporting disciplines to invest in the wellbeing of their athletes. RECENT FINDINGS Discerning physiological electrical alterations due to athletic training from those representing cardiac pathology may be challenging. The mode of investigation of affected athletes is dependent on the electrical anomaly and the disease(s) in question. This review will highlight specific pathological ECG patterns that warrant assessment and surveillance, together with an in-depth review of the recommended algorithm for evaluation.
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Affiliation(s)
- Mark Abela
- Cardiology Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK.
- University of Malta, Msida, Malta.
| | - Sanjay Sharma
- Cardiology Clinical Academic Group, St. George's, University of London, St. George's University Hospitals NHS Foundation Trust, London, UK
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36
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Sahashi Y, Watanabe T, Takasugi N, Yanagimoto TS, Okura H. Anterior early repolarization pattern and T‐wave inversion in a healthy African‐Japanese athlete. J Arrhythm 2019; 35:865-867. [PMID: 31844482 PMCID: PMC6898533 DOI: 10.1002/joa3.12241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 08/09/2019] [Accepted: 09/02/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Yuki Sahashi
- Department of Cardiology Gifu University Graduate School of Medicine Gifu Japan
| | - Takatomo Watanabe
- Department of Cardiology Gifu University Graduate School of Medicine Gifu Japan
| | - Nobuhiro Takasugi
- Department of Cardiology Gifu University Graduate School of Medicine Gifu Japan
| | | | - Hiroyuki Okura
- Department of Cardiology Gifu University Graduate School of Medicine Gifu Japan
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37
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Sharma S, Drezner JA, Baggish A, Papadakis M, Wilson MG, Prutkin JM, La Gerche A, Ackerman MJ, Borjesson M, Salerno JC, Asif IM, Owens DS, Chung EH, Emery MS, Froelicher VF, Heidbuchel H, Adamuz C, Asplund CA, Cohen G, Harmon KG, Marek JC, Molossi S, Niebauer J, Pelto HF, Perez MV, Riding NR, Saarel T, Schmied CM, Shipon DM, Stein R, Vetter VL, Pelliccia A, Corrado D. International recommendations for electrocardiographic interpretation in athletes. Eur Heart J 2019; 39:1466-1480. [PMID: 28329355 DOI: 10.1093/eurheartj/ehw631] [Citation(s) in RCA: 200] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 12/08/2016] [Indexed: 12/14/2022] Open
Abstract
Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.
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Affiliation(s)
- Sanjay Sharma
- Cardiology Clinical Academic Group, St George's, University of London, UK
| | - Jonathan A Drezner
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Aaron Baggish
- Division of Cardiology, Massachusettes General Hospital, MA, USA
| | - Michael Papadakis
- Cardiology Clinical Academic Group, St George's, University of London, UK
| | - Mathew G Wilson
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Qatar
| | - Jordan M Prutkin
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Andre La Gerche
- Department of Cardiology, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Michael J Ackerman
- Department of Cardiovascular Diseases, Pediatric and Adolescent Medicine, and Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, MN, USA
| | - Mats Borjesson
- Department of Neuroscience and Physiology, Sahlgrenska University Hospital/Ostra Sahlgrenska Academy, Goteborg, Sweden
| | - Jack C Salerno
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Irfan M Asif
- Department of Family Medicine, University of South Carolina, Greenville, SC, USA
| | - David S Owens
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Eugene H Chung
- Division of Cardiology, University of North Carolina School of Medicine, NC, USA
| | - Michael S Emery
- Center of Cardiovascular Care in Athletics, Indiana University School of Medicine, IN, USA
| | | | - Hein Heidbuchel
- Department of Cardiology, Arrhythmology Hasselt University, Hasselt, Belgium.,Department of Cardiology, Antwerp, Belgium
| | - Carmen Adamuz
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Qatar
| | | | - Gordon Cohen
- Division of Pediatric Cardiothoracic Surgery, University of California San Francisco School of Medicine, CA, USA
| | - Kimberly G Harmon
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | | | - Silvana Molossi
- Division of Pediatric Cardiology, Baylor College of Medicine, TX, USA
| | - Josef Niebauer
- University Institute of Sports Medicine, Paracelsus Medical University, Austria
| | - Hank F Pelto
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Marco V Perez
- Center for Inherited Cardiovascular Disease, Stanford University, CA, USA
| | - Nathan R Riding
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Qatar
| | - Tess Saarel
- Pediatric Cardiology, Cleveland Clinic, OH, USA
| | | | - David M Shipon
- Heart Center of Philadelphia, Jefferson University Hospitals, PA, USA
| | - Ricardo Stein
- Department of Cardiology, Hospital de Clinicas de Porte Allegre, Brazil
| | | | | | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Italy
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Schnell F. [ECG in sportsmen: Distinguishing the normal from the pathological]. Presse Med 2019; 48:1393-1400. [PMID: 31471091 DOI: 10.1016/j.lpm.2019.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 07/01/2019] [Indexed: 11/18/2022] Open
Abstract
An ECG is recommended by the French Society of Cardiology in the screening of a competitive athlete. An intense and prolonged physical activity (>4 hours of intense sport/week) can lead to a physiological electric remodeling. In addition to physical activity (type, intensity, duration), the ECG should be interpreted according to the athlete's ethnicity and age. It is necessary to know the physiological modifications related to sport practice to avoid either false reassurances or the realization of unjustified additional examinations because of a wrong interpretation. The latest athlete ECG classification published in 2017 can be used to identify in which athlete additional tests are recommended (figure 1).
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Affiliation(s)
- Frédéric Schnell
- CHU de Rennes, Université de Rennes 1, hôpital Pontchaillou, service de médecine du sport, LTSI-UMR, Inserm, 1099 Rennes, France.
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Affiliation(s)
- Thomas F Lüscher
- Imperial College and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals London, UK.,Center for Molecular Cardiology, University of Zurich, Switzerland.,EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, Zurich, Switzerland
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40
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Guasch E, Sanz-de la Garza M, Mont L. T-wave inversion in young athletes: Should we check their bones or their identity card? The quest for precision medicine. Eur J Prev Cardiol 2018; 26:638-640. [PMID: 30545251 DOI: 10.1177/2047487318820665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Eduard Guasch
- 1 Cardiovascular Institute, Hospital Clínic, Spain.,2 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain.,3 Universitat de Barcelona, Spain.,4 Centro de Inverstigación Biomédica en Red - Cardiovascular (CIBERCV), Spain
| | - Maria Sanz-de la Garza
- 1 Cardiovascular Institute, Hospital Clínic, Spain.,2 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain.,3 Universitat de Barcelona, Spain.,4 Centro de Inverstigación Biomédica en Red - Cardiovascular (CIBERCV), Spain
| | - Lluís Mont
- 1 Cardiovascular Institute, Hospital Clínic, Spain.,2 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain.,3 Universitat de Barcelona, Spain.,4 Centro de Inverstigación Biomédica en Red - Cardiovascular (CIBERCV), Spain
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41
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Brosnan MJ, te Riele AS, Bosman LP, Hoorntje ET, van den Berg MP, Hauer RN, Flannery MD, Kalman JM, Prior DL, Tichnell C, Tandri H, Murray B, Calkins H, La Gerche A, James CA. Electrocardiographic Features Differentiating Arrhythmogenic Right Ventricular Cardiomyopathy From an Athlete’s Heart. JACC Clin Electrophysiol 2018; 4:1613-1625. [DOI: 10.1016/j.jacep.2018.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/22/2018] [Accepted: 09/10/2018] [Indexed: 10/28/2022]
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12-Lead Electrocardiography Parameters for Differentiating Athlete's Heart From Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Clin Electrophysiol 2018; 4:1626-1628. [DOI: 10.1016/j.jacep.2018.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/08/2018] [Indexed: 11/20/2022]
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Abstract
Sudden cardiac death (SCD) is the leading cause of death in athletes. A large proportion of these deaths are associated with undiagnosed cardiovascular disease. Screening for high-risk individuals enables early detection of pathology, as well as permitting lifestyle modification or therapeutic intervention.ECG changes in athletes occur as a result of electrical and structural adaptations secondary to repeated bouts of exercise. Such changes are common and may overlap with patterns suggestive of underlying cardiovascular disease. Correct interpretation is therefore essential, in order to differentiate physiology from pathology. Erroneous interpretation may result in false reassurance or expensive investigations for further evaluation and unnecessary disqualification from competitive sports.Interpretation of the athlete's ECG has evolved over the past 12 years, beginning with the 2005 European Society of Cardiology (ESC) consensus, progressing to the ESC recommendations (2010), Seattle Criteria (2013) and the 'refined' criteria (2014). This evolution culminated in the recently published international recommendations for ECG interpretation in athletes (2017), which has led to a significant reduction in false positives and screening-associated costs. This review aims to describe the evolution of the current knowledge on ECG interpretation as well as future directions.
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Affiliation(s)
- Joyee Basu
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.
| | - Aneil Malhotra
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
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44
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McClean G, Riding NR, Pieles G, Sharma S, Watt V, Adamuz C, Johnson A, Tramullas A, George KP, Oxborough D, Wilson MG. Prevalence and significance of T-wave inversion in Arab and Black paediatric athletes: Should anterior T-wave inversion interpretation be governed by biological or chronological age? Eur J Prev Cardiol 2018; 26:641-652. [PMID: 30426769 DOI: 10.1177/2047487318811956] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND International electrocardiographic (ECG) recommendations regard anterior T-wave inversion (ATWI) in athletes under 16 years to be normal. DESIGN The aim of this study was to identify the prevalence, distribution and determinants of TWI by ethnicity, chronological and biological age within paediatric athletes. A second aim was to establish the diagnostic accuracy of international ECG recommendations against refinement within athletes who present with ECG variants isolated to ATWI (V1-V4) using receiver operator curve analysis. Clinical context was calculated using Bayesian analysis. METHODS Four hundred and eighteen Arab and 314 black male athletes (11-18 years) were evaluated by ECG, echocardiogram and biological age (by radiological X-ray) assessment. RESULTS A total of 116 (15.8%) athletes presented with ATWI (V1-V4), of which 96 (82.8%) were observed in the absence of other ECG findings considered to be abnormal as per international recommendations for ECG interpretation in athletes; 91 (12.4%) athletes presented with ATWI confined to V1-V3, with prevalence predicted by black ethnicity (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.3-3.5) and biological age under 16 years (OR 2.0, 95% CI 1.2-3.3). Of the 96 with ATWI (V1-V4) observed in the absence of other ECG findings considered to be abnormal, as per international recommendations for ECG interpretation in athletes, diagnostic accuracy was 'fail' (OR 0.47, 95% CI 0.00-1.00) for international recommendations and 'excellent' (OR 0.97, 95% CI 0.92-1.00) when governed by biological age under 16 years, providing a positive and negative likelihood ratio of 15.8 (95% CI 1.8-28.1) and 0.0 (95% CI 0.0-0.8), respectively. CONCLUSION Interpretation of ECG variants isolated with ATWI (V1-V4) using international recommendations (chronological age <16 years) warrants caution, but governance by biological age yielded an 'excellent' diagnostic accuracy. In the clinical context, the 'chance' of detecting cardiac pathology within a paediatric male athlete presenting with ATWI in the absence of other ECG findings considered to be abnormal, as per international recommendations for ECG interpretation in athletes (positive likelihood ratio 15.8), was 14.4%, whereas a negative ECG (negative likelihood ratio 0.0) was 0%.
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Affiliation(s)
- Gavin McClean
- 1 Athlete Health and Performance Research Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Qatar.,2 Research Institute for Sport and Exercise Science, Liverpool John Moores University, UK
| | - Nathan R Riding
- 1 Athlete Health and Performance Research Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Qatar
| | - Guido Pieles
- 3 National Institute for Health Research (NIHR) Cardiovascular Biomedical Research Centre, Bristol Royal Hospital for Children and Bristol Heart Institute, UK
| | - Sanjay Sharma
- 4 Department of Cardiovascular Sciences, St Georges University of London, UK
| | - Victoria Watt
- 5 Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Qatar
| | - Carmen Adamuz
- 5 Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Qatar
| | - Amanda Johnson
- 6 Aspire Academy Sports Medicine Centre, Aspire Academy, Qatar
| | | | - Keith P George
- 2 Research Institute for Sport and Exercise Science, Liverpool John Moores University, UK
| | - David Oxborough
- 2 Research Institute for Sport and Exercise Science, Liverpool John Moores University, UK
| | - Mathew G Wilson
- 1 Athlete Health and Performance Research Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Qatar.,2 Research Institute for Sport and Exercise Science, Liverpool John Moores University, UK
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45
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Kirchhof P, Fabritz L. Anterior T-Wave Inversion Does Not Convey Short-Term Sudden Death Risk: Inverted Is the New Normal. J Am Coll Cardiol 2018; 69:10-12. [PMID: 28057232 DOI: 10.1016/j.jacc.2016.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, University Hospital Birmingham Foundation National Health Service Trust, Birmingham, United Kingdom; Department of Cardiology, Division of Rhythmology, Hospital of the University of Münster, Münster, Germany; Department of Cardiology, Sandwell and West Birmingham Hospitals National Health Service Trust, Birmingham, United Kingdom.
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, University Hospital Birmingham Foundation National Health Service Trust, Birmingham, United Kingdom; Department of Cardiology, Division of Rhythmology, Hospital of the University of Münster, Münster, Germany
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Abstract
Purpose of the review For many years, competitive sport has been dominated by men. Recent times have witnessed a significant increase in women participating in elite sports. As most studies investigated male athletes, with few reports on female counterparts, it is crucial to have a better understanding on physiological cardiac adaptation to exercise in female athletes, to distinguish normal phenotypes from potentially fatal cardiac diseases. This review reports on cardiac adaptation to exercise in females. Recent findings Recent studies show that electrical, structural, and functional cardiac changes due to physiological adaptation to exercise differ in male and female athletes. Women tend to exhibit eccentric hypertrophy, and while concentric hypertrophy or concentric remodeling may be a normal finding in male athletes, it should be evaluated carefully in female athletes as it may be a sign of pathology. Although few studies on veteran female athletes are available, women seem to be affected by atrial fibrillation, coronary atherosclerosis, and myocardial fibrosis less than male counterparts. Summary Males and females exhibit many biological, anatomical, and hormonal differences, and cardiac adaptation to exercise is no exception. The increasing participation of women in sports should stimulate the scientific community to develop large, longitudinal studies aimed at a better understanding of cardiac adaptation to exercise in female athletes.
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Affiliation(s)
- Clea Simone S S Colombo
- MSc Sports Cardiology, Cardiology Clinical Academic Group, St George's University of London, Cranmer Terrace, SW 17 0RE, London, UK. .,Cuore Dello Sport, Valinhos, R. Luiz Spiandorelli Neto, 60, s307. Valinhos, São Paulo, Brazil.
| | - Gherardo Finocchiaro
- Cardiology Clinical Academic Group, St George's University of London, Cranmer Terrace, SW 17 0RE, London, UK
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47
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de Gregorio C, Di Nunzio D, Di Bella G. Athlete's Heart and Left Heart Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018. [PMID: 29532331 DOI: 10.1007/5584_2018_176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Physical activity comprises all muscular activities that require energy expenditure. Regular sequence of structured and organized exercise with the specific purpose of improving wellness and athletic performance is defined as a sports activity.Exercise can be performed at various levels of intensity and duration. According to the social context and pathways, it can be recreational, occupational, and competitive. Therefore, the training burden varies inherently and the heart adaptation is challenging.Although a general agreement on the fact that sports practice leads to metabolic, functional and physical benefits, there is evidence that some athletes may be subjected to adverse outcomes. Sudden cardiac death can occur in apparently healthy individuals with unrecognized cardiovascular disease.Thus, panels of experts in sports medicine have promoted important pre-participation screening programmes aimed at determining sports eligibility and differentiating between physiological remodeling and cardiac disease.In this review, the most important pathophysiological and diagnostic issues are discussed.
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Affiliation(s)
- Cesare de Gregorio
- Department of Clinical and Experimental Medicine - Cardiology Unit, University Hospital Medical School "Gaetano Martino", Messina, Italy.
| | - Dalia Di Nunzio
- Department of Clinical and Experimental Medicine - Cardiology Unit, University Hospital Medical School "Gaetano Martino", Messina, Italy
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine - Cardiology Unit, University Hospital Medical School "Gaetano Martino", Messina, Italy
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48
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Sheikh N, Papadakis M, Wilson M, Malhotra A, Adamuz C, Homfray T, Monserrat L, Behr ER, Sharma S. Diagnostic Yield of Genetic Testing in Young Athletes With T-Wave Inversion. Circulation 2018; 138:1184-1194. [PMID: 29764897 PMCID: PMC6147090 DOI: 10.1161/circulationaha.118.034208] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/08/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND T-wave inversion (TWI) is common in patients with cardiomyopathy. However, up to 25% of athletes of African/Afro-Caribbean descent (black athletes) and 5% of white athletes also have TWI of unclear clinical significance despite comprehensive clinical evaluation and long-term follow-up. The aim of this study was to determine the diagnostic yield from genetic testing, beyond clinical evaluation, when investigating athletes with TWI. METHODS We investigated 50 consecutive asymptomatic black and 50 white athletes 14 to 35 years of age with TWI and a normal echocardiogram who were referred to a UK tertiary center for cardiomyopathy and sports cardiology. Subjects underwent exercise testing, 24-hour ambulatory ECG, signal-averaged ECG, cardiac magnetic resonance imaging, and a blood-based analysis of a comprehensive 311-gene panel for cardiomyopathies and ion channel disorders associated with TWI, including hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, dilated cardiomyopathy, left ventricular noncompaction, long-QT syndrome, and Brugada syndrome. RESULTS In total, 21 athletes (21%) were diagnosed with cardiac disease on the basis of comprehensive clinical investigations. Of these, 8 (38.1%) were gene positive (myosin binding protein C[ MYBPC3], myosin heavy chain 7 [ MYH7], galactosidase alpha [ GLA], and actin alpha, cardiac muscle 1 [ ACTC1] genes) and 13 (61.9%) were gene negative. Of the remaining 79 athletes (79%), 2 (2.5%) were gene positive (transthyretin [ TTR] and sodium voltage-gated channel alpha subunit 5 [ SCN5A] genes) in the absence of a clinical phenotype. The prevalence of newly diagnosed cardiomyopathy was higher in white athletes compared with black athletes (30.0% versus 12%; P=0.027). Hypertrophic cardiomyopathy accounted for 90.5% of all clinical diagnoses. All black athletes and 93.3% of white athletes with a clinical diagnosis of cardiomyopathy or a genetic mutation capable of causing cardiomyopathy exhibited lateral TWI as opposed to isolated anterior or inferior TWI; the genetic yield of diagnoses from lateral TWI was 12.3%. CONCLUSIONS Up to 10% of athletes with TWI revealed mutations capable of causing cardiac disease. Despite the substantial cost, the positive diagnostic yield from genetic testing was one half that from clinical evaluation (10% versus 21%) and contributed to additional diagnoses in only 2.5% of athletes with TWI in the absence of a clear clinical phenotype, making it of negligible use in routine clinical practice.
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Affiliation(s)
- Nabeel Sheikh
- St. George’s University of London, United Kingdom (N.S., M.P., A.M., T.H., E.R.B., S.S.)
| | - Michael Papadakis
- St. George’s University of London, United Kingdom (N.S., M.P., A.M., T.H., E.R.B., S.S.)
| | - Mathew Wilson
- Aspetar, Qatar Orthopaedic and Sports Medicine Hospital, Doha (M.W., C.A.)
| | - Aneil Malhotra
- St. George’s University of London, United Kingdom (N.S., M.P., A.M., T.H., E.R.B., S.S.)
| | - Carmen Adamuz
- Aspetar, Qatar Orthopaedic and Sports Medicine Hospital, Doha (M.W., C.A.)
| | - Tessa Homfray
- St. George’s University of London, United Kingdom (N.S., M.P., A.M., T.H., E.R.B., S.S.)
| | | | - Elijah R. Behr
- St. George’s University of London, United Kingdom (N.S., M.P., A.M., T.H., E.R.B., S.S.)
| | - Sanjay Sharma
- St. George’s University of London, United Kingdom (N.S., M.P., A.M., T.H., E.R.B., S.S.)
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Finocchiaro G, Papadakis M, Dhutia H, Zaidi A, Malhotra A, Fabi E, Cappelletto C, Brook J, Papatheodorou E, Ensam B, Miles CJ, Bastiaenen R, Attard V, Homfray T, Sharma R, Tome M, Carr-White G, Merlo M, Behr ER, Sinagra G, Sharma S. Electrocardiographic differentiation between ‘benign T-wave inversion’ and arrhythmogenic right ventricular cardiomyopathy. Europace 2018; 21:332-338. [DOI: 10.1093/europace/euy179] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/12/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gherardo Finocchiaro
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Michael Papadakis
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Harshil Dhutia
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Abbas Zaidi
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Aneil Malhotra
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Elena Fabi
- Cardiovascular Department, ‘Ospedali Riuniti’ Hospital, University of Trieste, Trieste, Italy
| | - Chiara Cappelletto
- Cardiovascular Department, ‘Ospedali Riuniti’ Hospital, University of Trieste, Trieste, Italy
| | - Joe Brook
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Efstathios Papatheodorou
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Bode Ensam
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Christopher J Miles
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Rachel Bastiaenen
- Cardiovascular Department, Guy’s and St. Thomas’s Hospital, London, UK
| | - Virginia Attard
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Tessa Homfray
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Rajan Sharma
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Maite Tome
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Gerald Carr-White
- Cardiovascular Department, Guy’s and St. Thomas’s Hospital, London, UK
| | - Marco Merlo
- Cardiovascular Department, ‘Ospedali Riuniti’ Hospital, University of Trieste, Trieste, Italy
| | - Elijah R Behr
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Gianfranco Sinagra
- Cardiovascular Department, ‘Ospedali Riuniti’ Hospital, University of Trieste, Trieste, Italy
| | - Sanjay Sharma
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
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50
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Prutkin JM, Wilson MG. Electrocardiography in athletes: normal and abnormal findings. Heart 2018; 104:1902-1909. [PMID: 30121634 DOI: 10.1136/heartjnl-2017-312901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/16/2018] [Accepted: 07/23/2018] [Indexed: 12/19/2022] Open
Abstract
Many sporting organisations recommend a pre-participation ECG to screen for disorders which predispose to sudden cardiac arrest (SCA). The ability of the ECG to perform accurately is dependent on the ECG criteria used and the experience of the operator. There have been several ECG criteria over the last decade, though these were recently superseded with the publication of the 'International Consensus Criteria for ECG Interpretation in Athletes'. These criteria use the latest evidence to improve specificity while maintaining sensitivity for ECG-detectable pathologies associated with SCA. Accordingly, this review describes the normal, borderline and abnormal ECG findings in an asymptomatic athlete aged 12-35 years.
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Affiliation(s)
- Jordan M Prutkin
- Department of Medicine/Cardiology, University of Washington, Seattle, Washington, USA
| | - Mathew G Wilson
- Sports Medicine Department, ASPETAR Orthopaedic and Sports Medicine Hospital, Doha, Qatar.,Athlete Health and Performance Research Centre, ASPETAR Orthopaedic and Sports Medicine Hospital, Doha, Qatar
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