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Panhuyzen-Goedkoop NM, Verbeek ALM, Goedkoop RJ, Malekzadeh A, Wilde AAM, Peters RJG, Jørstad HT. Quality of athlete screening for high-risk cardiovascular conditions-A systematic review. Scand J Med Sci Sports 2023; 33:2094-2109. [PMID: 37449413 DOI: 10.1111/sms.14446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 04/21/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Sudden cardiac death (SCD) is the leading medical cause of death in athletes. To prevent SCD, screening for high-risk cardiovascular conditions (HRCC) is recommended. Screening strategies are based on a limited number of studies and expert consensus. However, evidence and efficacy of athlete HRCC screening is unclear. OBJECTIVE To determine methodological quality and quality of evidence of athlete screening, and screening efficacy to detect HRCC in a systematic review. METHODS We performed a systematic search of Medline, Embase, Scopus and Cochrane Library up to June 2021. We included articles containing original data of athlete cardiovascular screening, providing details of screening strategies, test results and HRCC detection. We assessed methodological quality of the included articles by QUADAS-2, quality of evidence of athlete HRCC screening by GRADE, and athlete HRCC screening efficacy by SWiM. RESULTS Of 2720 citations, we included 33 articles (1991-2018), comprising 82 417 athletes (26.7% elite, 73.4% competitive, 21.7% women, 75.2% aged ≤35). Methodological quality was 'very low' (33 articles), caused by absence of data blinding and inappropriate statistical analysis. Quality of evidence was 'very low' (33 articles), due to observational designs and population heterogeneity. Screening efficacy could not be reliably established. The prevalence of HRCC was 0.43% with false positive rate (FPR) 13.0%. CONCLUSIONS Methodological quality and quality of evidence on athlete screening are suboptimal. Efficacy could not be reliably established. The prevalence of screen detected HRCC was very low and FPR high. Given the limitations of the evidence, individual recommendations need to be prudent.
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Affiliation(s)
- Nicole M Panhuyzen-Goedkoop
- Department of Cardiology, Amsterdam University Medical Centers, Heart Centre, Amsterdam, The Netherlands
- Sports Medical Centre Papendal, Arnhem, The Netherlands
| | - André L M Verbeek
- Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Arjan Malekzadeh
- University Library, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Department of Cardiology, Amsterdam University Medical Centers, Heart Centre, Amsterdam, The Netherlands
| | - Ron J G Peters
- Department of Cardiology, Amsterdam University Medical Centers, Heart Centre, Amsterdam, The Netherlands
| | - Harald T Jørstad
- Department of Cardiology, Amsterdam University Medical Centers, Heart Centre, Amsterdam, The Netherlands
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2
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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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3
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Ross SB, Jones K, Blanch B, Puranik R, McGeechan K, Barratt A, Semsarian C. A systematic review and meta-analysis of the prevalence of left ventricular non-compaction in adults. Eur Heart J 2021; 41:1428-1436. [PMID: 31143950 DOI: 10.1093/eurheartj/ehz317] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/13/2018] [Accepted: 05/01/2019] [Indexed: 12/15/2022] Open
Abstract
AIMS To assess the reported prevalence of left ventricular non-compaction (LVNC) in different adult cohorts, taking in to consideration the role of diagnostic criteria and imaging modalities used. METHODS AND RESULTS A systematic review and meta-analysis of studies reporting LVNC prevalence in adults. Studies were sourced from Pre-Medline, Medline, and Embase and assessed for eligibility according to inclusion criteria. Eligible studies provided a prevalence of LVNC in adult populations (≥12 years). Studies were assessed, and data extracted by two independent reviewers. Fifty-nine eligible studies documenting LVNC in 67 unique cohorts were included. The majority of studies were assessed as moderate or high risk of bias. The pooled prevalence estimates for LVNC were consistently higher amongst cohorts diagnosed on cardiac magnetic resonance (CMR) imaging (14.79%, n = 26; I2 = 99.45%) compared with echocardiogram (1.28%, n = 36; I2 = 98.17%). This finding was unchanged when analysis was restricted to studies at low or moderate risk of bias. The prevalence of LVNC varied between disease and population representative cohorts. Athletic cohorts demonstrated high pooled prevalence estimates on echocardiogram (3.16%, n = 5; I2 = 97.37%) and CMR imaging (27.29%, n = 2). CONCLUSION Left ventricular non-compaction in adult populations is a poorly defined entity which likely encompasses both physiological adaptation and pathological disease. There is a higher prevalence with the introduction of newer imaging technologies, specifically CMR imaging, which identify LVNC changes more readily. The clinical significance of these findings remains unclear; however, there is significant potential for overdiagnosis, overtreatment, and unnecessary follow-up.
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Affiliation(s)
- Samantha B Ross
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney 2050, New South Wales, Australia.,Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney 2050, New South Wales, Australia
| | - Katherine Jones
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney 2050, New South Wales, Australia
| | - Bianca Blanch
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney 2050, New South Wales, Australia
| | - Rajesh Puranik
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney 2050, New South Wales, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney 2050, New South Wales, Australia
| | - Kevin McGeechan
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2050, New South Wales, Australia.,Wiser Healthcare, Sydney 2050, New South Wales, Australia
| | - Alexandra Barratt
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2050, New South Wales, Australia.,Wiser Healthcare, Sydney 2050, New South Wales, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney 2050, New South Wales, Australia.,Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney 2050, New South Wales, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney 2050, New South Wales, Australia.,Wiser Healthcare, Sydney 2050, New South Wales, Australia
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4
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Niederseer D, Rossi VA, Kissel C, Scherr J, Caselli S, Tanner FC, Bohm P, Schmied C. Role of echocardiography in screening and evaluation of athletes. Heart 2020; 107:heartjnl-2020-317996. [PMID: 33203709 DOI: 10.1136/heartjnl-2020-317996] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/19/2022] Open
Abstract
The term athlete's heart describes structural, functional and electrical adaptations of the cardiovascular system due to repetitive intense exercise. Physiological cardiac adaptations in athletes, however, may mimic features of cardiac diseases and therefore make it difficult to distinguish physiological adaptions from disease. Furthermore, regular exercise may also lead to pathological adaptions that can promote or worsen cardiac disease (eg, atrial dilation/atrial fibrillation, aortic dilation/aortic dissection and rhythm disorders). Sudden cardiac death (SCD) is a major concern in sports cardiology, and preparticipation screening (PPS) has demonstrated to be effective in identifying athletes at risk for SCD. In Europe, PPS is advocated to include personal and family history, physical examination and ECG, with further workup including echocardiography only if the initial screening investigations show abnormal findings. We review the current available evidence for echocardiography as a screening tool for conditions associated with SCD in recreational and professional athletes and advocate to include screening echocardiography to be performed at least twice in an athlete's career. We recommend that the first echocardiography is performed during adolescence to rule out structural heart conditions associated with SCD that cannot be detected by ECG, especially mitral valve prolapse, coronary artery anomalies, bicuspid aortic valve and dilatation of the aorta. A second echocardiography could be performed from the age of 30-35 years, when athletes age and become master athletes, to especially evaluate pathological cardiac remodelling to exercise (eg, atrial and/or right ventricular dilation), late onset cardiomyopathies and wall motion abnormalities due to myocarditis or coronary artery disease.
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Affiliation(s)
- David Niederseer
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Valentina Alice Rossi
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christine Kissel
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Johannes Scherr
- University Center for Prevention and Sports Medicine, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Stefano Caselli
- Cardiovascular Center Zurich, Hirslanden, Klinik im Park, Zurich, Switzerland
| | - Felix C Tanner
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Philipp Bohm
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Christian Schmied
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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5
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Riding NR, Sharma S, McClean G, Adamuz C, Watt V, Wilson MG. Impact of geographical origin upon the electrical and structural manifestations of the black athlete's heart. Eur Heart J 2019; 40:50-58. [PMID: 30169663 DOI: 10.1093/eurheartj/ehy521] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 08/08/2018] [Indexed: 07/13/2024] Open
Abstract
Aims Black athletes demonstrate an increased prevalence of repolarization anomalies and left ventricular hypertrophy compared to their white counterparts. Recent international recommendations for electrocardiogram (ECG) interpretation in athletes now account for some of these observations, but little attention is given to whether the heart of the black athlete is universal, or whether substantial differences exist according to geographic origin. Our aim was to examine the impact of geographical origin upon the electrical-and structural manifestations of the black athlete's heart. Methods and results A total of 1698 male competitive athletes participating in mixed sports presented at our organization for 12 lead-ECG led pre-participation screening, with 1222 athletes undergoing systematic echocardiography. Black athletes were categorized against United Nations defined geographical regions (North, East, Middle and West Africa, African American/Caribbean, South American, and West Asia) and compared with a cohort of non-black athletes who shared a close geographical boarder with Africa (South European White and Arabic North African). The prevalence of an abnormal ECG suggestive of cardiac pathology significantly varied by geographical origin. Repolarization abnormalities were significantly more common among West (6.4%) and Middle African (8.5%) athletes than East (1.5%) and North Africans (1.2%) (P < 0.05). Left ventricular hypertrophy was significantly more common among African-American/Caribbean (9.5%) and West African (5%) athletes than West Asian (0.8%), East African (0%), and North African (0%) athletes (P < 0.05). This result remained after accounting for body size. Conclusion The collective term 'black' should not imply that the hearts of all black athletes are universally comparable. There is considerable variability in the cardiac electrical and structural remodelling response to exercise that appears to be dependent on geographic origin.
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Affiliation(s)
- Nathan R Riding
- Athlete Health and Performance Research Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Sports City Street, Doha, Qatar
| | - Sanjay Sharma
- Cardiology Clinical and Academic Group, St George's, University of London, Cranmer Terrace, London, UK
| | - Gavin McClean
- Athlete Health and Performance Research Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Sports City Street, Doha, Qatar
- Research Institute for Sport and Exercise Science, Liverpool John Moores University, Tom Reilly Building, Liverpool, UK
| | - Carmen Adamuz
- Department of Sports Medicine, Aspetar, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Sports City Street, Doha, Qatar
| | - Victoria Watt
- Department of Sports Medicine, Aspetar, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Sports City Street, Doha, Qatar
| | - Mathew G Wilson
- Athlete Health and Performance Research Centre, Aspetar Orthopaedic and Sports Medicine Hospital, Sports City Street, Doha, Qatar
- Research Institute for Sport and Exercise Science, Liverpool John Moores University, Tom Reilly Building, Liverpool, UK
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6
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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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7
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McClean G, Riding NR, Ardern CL, Farooq A, Pieles GE, Watt V, Adamuz C, George KP, Oxborough D, Wilson MG. Electrical and structural adaptations of the paediatric athlete’s heart: a systematic review with meta-analysis. Br J Sports Med 2017; 52:230. [DOI: 10.1136/bjsports-2016-097052] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2017] [Indexed: 01/27/2023]
Abstract
AimTo describe the electrocardiographic (ECG) and echocardiographic manifestations of the paediatric athlete’s heart, and examine the impact of age, race and sex on cardiac remodelling responses to competitive sport.DesignSystematic review with meta-analysis.Data sourcesSix electronic databases were searched to May 2016: MEDLINE, PubMed, EMBASE, Web of Science, CINAHL and SPORTDiscus.Inclusion criteria(1) Male and/or female competitive athletes, (2) participants aged 6–18 years, (3) original research article published in English language.ResultsData from 14 278 athletes and 1668 non-athletes were included for qualitative (43 articles) and quantitative synthesis (40 articles). Paediatric athletes demonstrated a greater prevalence of training-related and training-unrelated ECG changes than non-athletes. Athletes ≥14 years were 15.8 times more likely to have inferolateral T-wave inversion than athletes <14 years. Paediatric black athletes had significantly more training-related and training-unrelated ECG changes than Caucasian athletes. Age was a positive predictor of left ventricular (LV) internal diameter during diastole, interventricular septum thickness during diastole, relative wall thickness and LV mass. When age was accounted for, these parameters remained significantly larger in athletes than non-athletes. Paediatric black athletes presented larger posterior wall thickness during diastole (PWTd) than Caucasian athletes. Paediatric male athletes also presented larger PWTd than females.ConclusionsThe paediatric athlete’s heart undergoes significant remodelling both before and during ‘maturational years’. Paediatric athletes have a greater prevalence of training related and training-unrelated ECG changes than non-athletes, with age, race and sex mediating factors on cardiac electrical and LV structural remodelling.
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8
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Malhotra VK, Singh N, Bishnoi RS, Chadha DS, Bhardwaj P, Madan H, Dutta R, Ghosh AK, Sengupta S, Perumal P. The prevalence of abnormal ECG in trained sportsmen. Med J Armed Forces India 2015; 71:324-9. [PMID: 26663958 DOI: 10.1016/j.mjafi.2015.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 06/08/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Competitive sports training causes structural and conductive system changes manifesting by various electrocardiographic alterations. We undertook this study to assess the prevalence of abnormal ECG in trained Indian athletes and correlate it with the nature of sports training, that is endurance or strength training. METHODS We evaluated a standard resting, lying 12 lead Electrocardiogram (ECG) in 66 actively training Indian athletes. Standard diagnostic criteria were used to define various morphological ECG abnormalities. RESULTS 33/66 (50%) of the athletes were undertaking endurance training while the other 33 (50%) were involved in a strength-training regimen. Overall 54/66 (81%) sportsmen had significant ECG changes. 68% of these changes were considered as normal training related features, while the remaining 32% were considered abnormal. There were seven common training related ECG changes-Sinus Bradycardia (21%), Sinus Arrhythmia (16%), 1st degree Atrioventricular Heart Block (6%), Type 1 2nd-degree Atrioventicular Heart Block (3%), Incomplete Right bundle branch block (RBBB) (24%), Early Repolarization (42%), Left Ventricular Hypertrophy (LVH) (14%); while three abnormal ECG changes--T-wave inversion (13%), RBBB(4%), Right ventricular hypertrophy (RVH) with strain (29%) were noted. Early repolarization (commonest change), sinus bradycardia, and incomplete RBBB were the commoner features noticed, with a significantly higher presence in the endurance trained athletes. CONCLUSION A high proportion of athletes undergoing competitive level sports training are likely to have abnormal ECG recordings. Majority of these are benign, and related to the physiological adaptation to the extreme levels of exertion. These changes are commoner during endurance training (running) than strength training (weightlifting).
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Affiliation(s)
- V K Malhotra
- Sports Physiologist, Army Sports Institute, Pune 411036, India
| | - Navreet Singh
- Classified Specialist (Medicine) and Cardiologist, Army Hospital (Research & Referral), New Delhi, 110011, India
| | - R S Bishnoi
- Commanding Officer, Army Sports Institute, Pune 411036, India
| | - D S Chadha
- Senior Adviser (Medicine) and Cardiology, Military Hospital (Cardiothoracic Center), Pune 411040, India
| | - P Bhardwaj
- Consultant (Medicine) and Cardiologist, Army Hospital (Research & Referral), New Delhi 110011, India
| | - H Madan
- Senior Adviser (Medicine) and Cardiologist, Army Hospital (Research & Referral), New Delhi 110011, India
| | - R Dutta
- Consultant (Medicine) and Cardiologist, & Commandant, Armed Forces Clinic, Dalhousie Road, New Delhi 110001, India
| | - A K Ghosh
- Senior Adviser (Medicine) and Cardiology, Command Hospital (Southern Command), Pune 411040, India
| | - S Sengupta
- Classified Specialist (Medicine) and Cardiologist, Military Hospital Jalandhar, Punjab, India
| | - P Perumal
- Nursing Assistant (Cardiology), Command Hospital (Southern Command), Pune 411040, India
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Abstract
Athletic intensive exercise is associated with repolarization changes affecting the ST-segment and T-wave morphology. The prevalence and distribution of these alterations are influenced by several demographic factors. One of the most challenging conundrums for both the cardiologist and the sports medicine physician is the correct interpretation of these repolarization changes to prevent an erroneous diagnosis with potentially serious consequences. A 12-lead electrocardiogram (ECG) demonstrating inverted T-waves may represent the first and only sign of such inherited heart muscle diseases, and may precede the detection of any structural changes in the heart, however, T-wave inversion in leads V1-V4 in black athletes may represent ethnic variation which is exaggerated by exercise.
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Affiliation(s)
- Ricardo Stein
- Universidade Federal do Rio Grande do Sul, Cardiology Division, and Exercise Cardiology Research Group (CardioEx), Vitta Centro de Bem Estar Físico, Porto Alegre, Brazil.
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10
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Uberoi A, Sadik J, Lipinski MJ, Van Le V, Froelicher V. Association between cardiac dimensions and athlete lineup position: analysis using echocardiography in NCAA football team players. PHYSICIAN SPORTSMED 2013; 41:58-66. [PMID: 24113703 DOI: 10.3810/psm.2013.09.2025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In determining what is "abnormal"-in terms of cardiac electrical and morphologic remodeling in athletes-it is important to identify what is "normal" or expected. With specialization for each position in a football team lineup, we attempted to describe the association between the position played and the physiologic cardiac changes of designated players. We evaluated data from 85 National College Athletic Association football players from a single team. The participants were assigned to 1 of 3 groups based on position and training regimen: lineman (n = 34), mobility/power players (n = 13), and skill players (n = 38). Players underwent assessment with electrocardiography and echocardiography (ECHO), with results interpreted by reviewers blinded to players' positions. Linemen were found to have greater body mass index and body surface area (BSA), as well as longer QRS duration (102 ± 10 ms vs 101 ± 7 ms in mobility/power players, and 96 ± 7 ms in skill players; P < 0.007). Left ventricular (LV) voltage values were lower in linemen (27.7 ± 6.5 mV vs 28.8 ± 7 mV in mobility/power players, and 31.8 ± 7.6 mV in skill players; both, P < 0.05). No differences in ejection fraction between groups were revealed on ECHO, but ECHO did show greater calculated LV mass, LV end-diastolic diameter, aortic root diameter, and LV outflow tract diameter in linemen, whether adjusted for BSA or not, and the differences were statistically different. Multivariate analysis showed that position (P < 0.0004 and QRS duration (P = 0.03) predicted LV mass. Echocardiographic variables found to be associated with player position included LV mass adjusted for BSA (P < 0.0001), LV end-diastolic diameter adjusted for BSA (P < 0.0003), and QTc interval (P = 0.007). On multivariate analysis, racial identity did not demonstrate significant differences; however, differences existed on univariate analysis of electrocardiography and ECHO variables, mostly in skill players. In skill players, QRS duration was shorter in the African American (AA) subgroup compared with that in the white/other subgroup. Lateral ST elevation and LV end-systolic volume were greater in AA players after adjustment for BSA, and AA linemen had greater LV posterior wall thickness after adjustment for BSA. In summary, we found that football players who are linemen had greater heart mass than did other players, despite adjustments for body size.
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Affiliation(s)
- Abhimanyu Uberoi
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA.
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11
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Gawroński W, Sobiecka J, Malesza J. Fit and healthy Paralympians—medical care guidelines for disabled athletes: a study of the injuries and illnesses incurred by the Polish Paralympic team in Beijing 2008 and London 2012. Br J Sports Med 2013; 47:844-9. [DOI: 10.1136/bjsports-2013-092298] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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12
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Affiliation(s)
- Philipp Bohm
- a Institute of Sports and Preventive Medicine , Saarland University , Saarbrücken , Germany
| | | | - Tim Meyer
- a Institute of Sports and Preventive Medicine , Saarland University , Saarbrücken , Germany
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13
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Bohm P, Ditzel R, Ditzel H, Urhausen A, Meyer T. Resting ECG findings in elite football players. J Sports Sci 2013; 31:1475-80. [DOI: 10.1080/02640414.2013.796067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Philipp Bohm
- a Institute of Sports and Preventive Medicine , Saarland University , Saarbrücken , Germany
| | - Roman Ditzel
- b Medical Office (for internal medicine) Mönchengladbach , Mönchengladbach , Germany
| | - Heribert Ditzel
- b Medical Office (for internal medicine) Mönchengladbach , Mönchengladbach , Germany
| | - Axel Urhausen
- c Center of Locomotor System, Sports Medicine and Prevention, Centre Hospitalier de Luxembourg et CRP-santé , Luxembourg
| | - Tim Meyer
- a Institute of Sports and Preventive Medicine , Saarland University , Saarbrücken , Germany
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14
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Schmied C, Drezner J, Kramer E, Dvorak J. Cardiac events in football and strategies for first-responder treatment on the field. Br J Sports Med 2013; 47:1175-8. [DOI: 10.1136/bjsports-2012-091918] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Schmied C, Di Paolo FM, Zerguini AY, Dvorak J, Pelliccia A. Screening athletes for cardiovascular disease in Africa: a challenging experience. Br J Sports Med 2013; 47:579-84. [DOI: 10.1136/bjsports-2012-091803] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Luijkx T, Cramer MJ, Zaidi A, Rienks R, Senden PJ, Sharma S, van Hellemondt FJ, Buckens CF, Mali WP, Velthuis BK. Ethnic differences in ventricular hypertrabeculation on cardiac MRI in elite football players. Neth Heart J 2013; 20:389-95. [PMID: 22777563 DOI: 10.1007/s12471-012-0305-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Left ventricular (LV) trabeculation may be more pronounced in ethnic African than in Caucasian (European) athletes, leading to possible incorrect diagnosis of left ventricular non-compaction cardiomyopathy (LVNC). This study investigates ethnic differences in LV hypertrabeculation amongst elite athletes with cardiac magnetic resonance (CMR) and electrocardiography (ECG). METHODS 38 elite male football (soccer) players (mean age 23.0, range 19-34 years, 28/38 European, 10/38 African) underwent CMR and ECG. Hypertrabeculation was assessed using the ratio of non-compacted to compacted myocardium (NC/C ratio) on long-axis and short-axis segments. ECGs were systematically rated. RESULTS No significant differences were seen in ventricular volumes, wall mass or E/A ratio, whereas biventricular ejection fraction (EF) was significantly lower in African athletes (European/African athletes LVEF 55/50 %, p = 0.02; RVEF 51/48 %, p = 0.05). Average NC/C ratio was greater in African athletes but only significantly at mid-ventricular level (European/African athletes: apical 0.91/1.00, p = 0.65; mid-ventricular 0.89/1.45, p < 0.05; basal 0.40/0.46, p = 0.67). ECG readings demonstrated no significant group differences, and no correlation between ECG anomalies and hypertrabeculation. CONCLUSIONS A greater degree of LV hypertrabeculation is seen in healthy African athletes, combined with biventricular EF reduction at rest. Recognition of this phenomenon is necessary to avoid misdiagnosis of LVNC.
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Affiliation(s)
- T Luijkx
- Department of Radiology, University Medical Center Utrecht, room E 01.132, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands,
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Halkin A, Steinvil A, Rosso R, Adler A, Rozovski U, Viskin S. Preventing sudden death of athletes with electrocardiographic screening: what is the absolute benefit and how much will it cost? J Am Coll Cardiol 2013. [PMID: 23194938 DOI: 10.1016/j.jacc.2012.09.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study sought to estimate the costs of a national electrocardiographic (ECG) screening of athletes in the United States and the number of lives that would be saved by that program. BACKGROUND A single study from Italy suggests that mandatory ECG screening of athletes reduces their risk of sudden cardiac death. Based on that study, ECG screening of athletes is endorsed by the European Society of Cardiology, though not by the American Heart Association. The widespread application of ECG screening remains controversial because the absolute reduction of sudden cardiac death risk provided, and its economic ramifications, have not been studied in detail. METHODS A cost-projection model was based on the Italian study, replicating its data in terms of athlete characteristics and physician performance. The size of the screening-eligible population was estimated from data provided by the National Collegiate Athletic Association and the National Federation of State High School Associations. The costs of diagnostic tests were obtained from Medicare reimbursement rates. RESULTS A 20-year program of ECG screening of young competitive athletes in the United States would cost between $51 and $69 billion and could be expected to save 4,813 lives. Accordingly, the cost per life saved is likely to range between $10.6 and $14.4 million. CONCLUSIONS Our cost-projection model suggests that replicating the Italian strategy of ECG screening in the United States would result in enormous costs per life saved.
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Affiliation(s)
- Amir Halkin
- Department of Cardiology, Sourasky Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Sliwa K, Lee GA, Carrington MJ, Obel P, Okreglicki A, Stewart S. Redefining the ECG in urban South Africans: electrocardiographic findings in heart disease-free Africans. Int J Cardiol 2012; 167:2204-9. [PMID: 22795400 DOI: 10.1016/j.ijcard.2012.06.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 06/06/2012] [Accepted: 06/06/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND The 12-lead electrocardiogram (ECG) represents an important diagnostic tool for detecting heart disease, but the "normal" ECG in those of African descent has yet to be definitively described. METHODS We systematically analysed 12-lead ECGs from 387 urban South Africans determined to be heart disease free (using the Minnesota code) following advanced cardiologic assessment, including echocardiography, at the Baragwanath Hospital in Soweto, South Africa. RESULTS 123 males (32%, 41.2 ± 14.5 years) and 264 females (37.4 ± 14.2 years) were studied. Most were in sinus rhythm (87%) and had normal axis (89%). Mean interval data were: PR interval (156 ± 28 ms; 95% CI: 153-159 ms), QRS duration (82 ± 16 ms; 95% CI: 80-84 ms), QT interval (379 ± 48 ms; 95% CI: 374-384 ms) and QTc interval (426 ± 32 ms; 95% CI: 423-429 ms). Overall, 199 (51%; 95% CI: 46.0% to 56.0%) subjects had an ECG "abnormality" or normal variant and 67 ECGs (17%; 95% CI: 13.3% to 20.7%) had major and minor abnormalities. ECG changes normally ascribed to myocardial ischaemia were: i) ST elevation (9.3%; 95% CI: 6.2 to 11.9%), ii) Q waves (7.4%; 95% CI: 4.4 to 9.5%) and iii) ST depression (2.3%; 95% CI: 0.8 to 3.8%). Sokolow-Lyon Index voltage exceeding 38 mm indicative of left ventricular hypertrophy was more prominent in males than females (23.6% vs. 6.4%; OR=4.5; 95% CI: 2.3-8.5). CONCLUSIONS These data provide a contemporary reference to the 12-lead ECG in urban South Africans found to be heart disease free, with both major and minor abnormalities detected.
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Affiliation(s)
- Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa & IIDMM, Faculty of Health Sciences, University of Cape Town, South Africa.
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Di Paolo FM, Schmied C, Zerguini YA, Junge A, Quattrini F, Culasso F, Dvorak J, Pelliccia A. The athlete's heart in adolescent Africans: an electrocardiographic and echocardiographic study. J Am Coll Cardiol 2012; 59:1029-36. [PMID: 22402076 DOI: 10.1016/j.jacc.2011.12.008] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 11/10/2011] [Accepted: 12/04/2011] [Indexed: 10/28/2022]
Abstract
OBJECTIVES The goal of this study was to define electrocardiographic (ECG) and echocardiographic characteristics of adolescent African athletes. BACKGROUND Recent observations in African athletes reported large prevalence of left ventricular (LV) hypertrophy and ECG abnormalities. No data, so far, exist for adolescent Africans, which comprise a growing proportion of competitive/professional athletes. METHODS The study included 154 soccer players participating at the 8th African Under-17 Championship of 2009, representing Algeria, Burkina Faso, Cameroon, Gambia, Guinea, Malawi, Nigeria, and Zimbabwe. For comparison, 62 Italian players with similar ages, sport achievements, and training schedules were included. RESULTS African athletes showed higher R5/S1-wave voltages than Caucasian athletes (48.6 ± 12.1 mm vs. 34.1 ± 8.9 mm; p < 0.01), larger prevalence of ECG LV hypertrophy (89% vs. 42%; p < 0.001), ST-segment elevation (91% vs. 56%; p < 0.001), and deeply inverted, or diffusely flat/biphasic, T waves (14% vs. 3% [p < 0.05] and 25% vs. 8% [p < 0.008], respectively). LV wall thicknesses were increased in Africans by 5% compared with Caucasians, and exceeded normal limits (≥13 mm) in 4 Africans but in no Caucasians. No athlete showed evidence of cardiomyopathies (i.e., hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy). On individual analysis, Algerians showed lower R/S-wave voltages compared with other African athletes. Increased wall thickness (≥13 mm) was observed only in sub-Saharian athletes (from Burkina Faso, Cameroon, and Niger). CONCLUSIONS African athletes displayed large proportion of ECG abnormalities, including a striking increase in R/S-wave voltage, ST-segment elevation, and deeply inverted or diffusely flat T waves by adolescence. LV remodeling in African athletes was characterized by a disproportionate wall thickening than in Caucasians but similar cavity size. Finally, distinctive peculiarities existed in African athletes according to the country (and ethnic) origin.
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Uberoi A, Stein R, Perez MV, Freeman J, Wheeler M, Dewey F, Peidro R, Hadley D, Drezner J, Sharma S, Pelliccia A, Corrado D, Niebauer J, Estes NAM, Ashley E, Froelicher V. Interpretation of the electrocardiogram of young athletes. Circulation 2011; 124:746-57. [PMID: 21824936 DOI: 10.1161/circulationaha.110.013078] [Citation(s) in RCA: 162] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Abhimanyu Uberoi
- Stanford University School of Medicine, Palo Alto, CA 94305, USA
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La Gerche A, MacIsaac AI, Prior DL. Should Pre-participation Cardiovascular Screening for Competitive Athletes be Introduced in Australia? A Timely Debate in a Sport-loving Nation. Heart Lung Circ 2011; 20:629-33. [DOI: 10.1016/j.hlc.2010.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Geyer R, Predel HG, Wolber T, Mellwig KP, Schmied C. Pre-competition cardiac screening in professional handball players - setting up at the EHF European Handball Championship 2010 in Austria. Wien Med Wochenschr 2011; 161:387-93. [PMID: 21953430 DOI: 10.1007/s10354-011-0018-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Accepted: 07/01/2011] [Indexed: 01/02/2023]
Abstract
In many sports, regular cardiac screening for exercise-associated sudden cardiac death is still not provided. To set up the current situation in top-skilled handball players qualified for the 2010 European Handball Championship in Austria, a standardised questionnaire was sent to every team. The fact that only 42.7% of the players returned the questionnaire may lead to the conclusion that the awareness of the problem is quite low. However, 82% of these players have been screened according to current recommendations. Half of the teams were screened inhomogeneously: 5 players (4.1%) have not been screened within the last years, 1 athlete (0.8%) was screened without an ECG. While 69% of the athletes got their first screening only after the age of 18, 16 players (13.1%) never went through a specific screening ever. We identified 17 athletes (13.9%) with a highly suspicious history, 2 of them (1.6%) never underwent a medical screening at all.
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Affiliation(s)
- Reinhard Geyer
- Department of Internal Medicine, Division of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
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Finsterer J, Höftberger R, Stöllberger C, Kanzler M. Metabolic myopathy with noncompaction in an African. Int J Cardiol 2011; 151:e58-60. [DOI: 10.1016/j.ijcard.2010.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Revised: 05/03/2010] [Accepted: 05/16/2010] [Indexed: 10/19/2022]
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Stollberger C, Finsterer J. A diagnostic dilemma in non-compaction, resulting in near expulsion from the football world cup. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 12:E8. [DOI: 10.1093/ejechocard/jeq110] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Sedehi D, Ashley EA. Defining the limits of athlete's heart: implications for screening in diverse populations. Circulation 2010; 121:1066-8. [PMID: 20176992 DOI: 10.1161/cir.0b013e3181d7308a] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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