Athletic dysrhythmias. A case report and review of the phenomenon of the 'athlete's heart'

[Anesthesia in high class athletes]

A case of general anaesthesia in a 49 year old male, high level specialist in triathlon, is reported. At the preoperative assessment, the patient had a sinus bradycardia of 45 b.min-1. The electrocardiogram (ECG) exhibited 2 mm ST segment elevation in leads V3-V5, an inverted T wave in leads V1 and V4, and a prolonged QT interval. The QRS axis was 60 degrees, the Sokolow index 44 mm; there was a partial right bundle branch block. These ECG anomalies disappeared during exercise. Heart sounds and blood pressure were normal. On chest X-ray the heart was enlarged. Five mg of midazolam were given orally 30 min before induction, and 1 mg atropine intravenously to increase the heart rate (40 b.min-1). Anaesthesia was induced with 2.5 mg.kg-1 propofol and alfentanil 15 micrograms.kg-1. Vecuronium 0.05 mg.kg-1, alfentanil 0.5 mg, 0.5% isoflurane in a mixture of 40% oxygen and 60% nitrous oxide were used to maintain anaesthesia. A further bolus of 0.5 mg atropine was necessary because of persisting sinus bradycardia. Surgery lasted 70 min. Heart rate and blood pressure returned to their initial values when the patient recovered from anaesthesia. Cardiac abnormalities are common in athletes; they must be distinguished from pathological conditions. When carrying out anaesthesia in these patients, it would seem highly recommendable to give 1-2 mg atropine, and to avoid associating negative chronotropic drugs.

Complete heart block during anaesthesia in a patient with sarcoidosis

An apparently fit young man with sarcoidosis developed complete heart block during an emergency mastoidectomy. A temporary transvenous pacemaker was inserted, but permanent pacing was required in the postoperative period. The clinical and pathological features of cardiac sarcoidosis are described; complete heart block is the commonest presentation of cardiac involvement. The role of anaesthesia as the precipitating factor in this case is discussed.

Multiple electrocardiographic anomalies during anaesthesia in an athlete

A 22-year-old athlete was scheduled for a minor surgical procedure under general anaesthesia. During anaesthesia, his electrocardiogram demonstrated multiple episodes of dysrhythmias including complete bundle branch block, atrioventricular (AV) block, isorhythmic atrioventricular dissociation with junctional rhythm. Administration of atropine 1.0 mg IV terminated the last episode of dysrhythmias. Postoperatively, a resting 12-lead electrocardiogram showed first degree AV block, ST-segment elevation and prominent U waves. A 24 hour Holter recording demonstrated first degree atrioventricular block, episodes of marked sinus arrhythmias and one episode of sinus tachycardia at a rate of 152 beats X min-1. Treadmill stress testing revealed peak achieved heart rate of 200 beats X min-1 without ischaemia. These findings collectively indicated athletic heart syndrome. Implications of athletic heart syndrome for the anaesthetist are reviewed and discussed.