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Zhang S, Jin P, Yang L, Zeng Y, Li Y, Tang R. Exploration of Clozapine-Induced Cardiomyopathy and Its Mechanism. Cardiovasc Toxicol 2024:10.1007/s12012-024-09909-7. [PMID: 39153146 DOI: 10.1007/s12012-024-09909-7] [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] [Received: 03/15/2023] [Accepted: 08/05/2024] [Indexed: 08/19/2024]
Abstract
In this study, by pooling the clinical data of patients who died with a history of long-term clozapine use and by examining their hearts, it was found that long-term clozapine use can lead to cardiomyopathy and that its presentation resembles arrhythmogenic cardiomyopathy (ACM), i.e., it exhibits a predominantly right ventricular fatty infiltration with mild left ventricular damage. The transcriptomic data of rat cardiomyocytes after clozapine intervention were analyzed by transcriptomic approach to explore the causes of clozapine cardiomyopathy. The cause of clozapine cardiomyopathy was then explored by a transcriptomic approach, which revealed that its clozapine action on cardiomyocytes enriched cardiomyocyte-related differential genes in biological processes such as muscle development and response to hypoxia, as well as pathways such as fatty acid metabolism and cellular autophagy. Transcriptomic analysis showed that Egr1, Egr2, ler2, Jun, Mapk9, Nr1d2, Atf3, Bhlhe40, Crem, Cry1, Cry2, Dbp were hub genes for clozapine injury to the myocardium, and that these genes may play an important role in the myocardial ACM-like changes caused by clozapine. Combined with the results of pathological examination and transcriptomic analysis, it can be concluded that the long-term action of clozapine on cardiomyocytes leads to cellular autophagy and subsequent structural remodeling of the heart, and in the remodeling affects fatty acid metabolism, which eventually leads to ACM-like changes.
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Affiliation(s)
- Shangyu Zhang
- Department of Forensic Medicine, College of Basic Medicine, Chongqing Medical University, Medical College Road, Yuzhong District, Chongqing, China
| | - Pengyue Jin
- Department of Forensic Medicine, College of Basic Medicine, Chongqing Medical University, Medical College Road, Yuzhong District, Chongqing, China
| | - Li Yang
- Department of Forensic Medicine, College of Basic Medicine, Chongqing Medical University, Medical College Road, Yuzhong District, Chongqing, China
| | - Yujie Zeng
- Department of Forensic Medicine, College of Basic Medicine, Chongqing Medical University, Medical College Road, Yuzhong District, Chongqing, China
| | - Yongguo Li
- Department of Forensic Medicine, College of Basic Medicine, Chongqing Medical University, Medical College Road, Yuzhong District, Chongqing, China
| | - Renkuan Tang
- Department of Forensic Medicine, College of Basic Medicine, Chongqing Medical University, Medical College Road, Yuzhong District, Chongqing, China.
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2
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Allwood RP. Apicolateral bulge: A potential mimic of arrhythmogenic right ventricular cardiomyopathy in a professional athlete-A case report and literature review. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024. [PMID: 39021260 DOI: 10.1002/jcu.23761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/26/2024] [Indexed: 07/20/2024]
Abstract
Soccer is the most popular sport in the world, with over 265 million active players and approximately 0.05% professional players worldwide. The Fédération Internationale de Football Association (FIFA) has made preparticipation screening recommendations which involve electrocardiography and echocardiography being performed prior to international competition. The aim of preparticipation cardiovascular screening in young athletes is to detect asymptomatic individuals with cardiovascular disease at risk of sudden cardiac death (SCD). The incidence of SCD in young athletes (age≤ 35 years) is 0.6-3.6 in 100,000 persons/year, with most deaths due to cardiovascular causes. Arrhythmogenic right ventricular cardiomyopathy (ARVC) is one of the leading causes of SCD in young athletes. It is a genetic disease characterized by progressive fibrofatty replacement of the myocardium with variable phenotypic expression. Exercise-induced cardiac remodeling in conjunction with extensive T-wave inversion raises concern for ARVC. This case report and literature review explores a potential mimic for ARVC, the role of cardiovascular screening in sport, and the use of a multimodality approach for risk stratification and management.
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Affiliation(s)
- Richard P Allwood
- Cardiology Department, Baker Heart and Diabetes Institute, Melbourne, Australia
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3
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Monda E, Bakalakos A, Lachmann R, Syrris P, Limongelli G, Murphy E, Hughes D, Elliott PM. Incidence and risk factors for development of left ventricular hypertrophy in Fabry disease. Heart 2024; 110:846-853. [PMID: 38688703 DOI: 10.1136/heartjnl-2023-323783] [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: 12/07/2023] [Accepted: 04/20/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Left ventricular hypertrophy (LVH) is the principal cardiac manifestation of Fabry disease (FD). This study aimed to determine the incidence and predictors of LVH development in a contemporary cohort of patients with FD and no LVH at baseline evaluation. METHODS Consecutively referred adult (aged ≥16 years) patients with FD were enrolled into an observational cohort study. Patients were prospectively followed in a specialist cardiomyopathy centre and the primary endpoint was the first detection of LVH (left ventricular mass index (LVMi) ≥115 g/m2 in men and ≥95 g/m2 in women). RESULTS From a cohort of 393 patients, 214 (aged 35.8±13.8 years; 61 (29%) males) had no LVH at first evaluation. During a median follow-up of 9.4 years (IQR 4.7-12.7), 55 patients (24.6%) developed LVH. The estimated incidence of LVH was 11.3% (95% CI 6.5% to 16.1%) at 5 years, 29.1% (95% CI 21.5% to 36.7%) at 10 years and 45.0% (95% CI 33.8% to 62.4%) at 15 years of follow-up. On multivariable analysis, independent predictors for LVH development were age (HR 1.04 (95% CI 1.02 to 1.06) per 1-year increase, p<0.001), male sex (HR 2.90 (95% CI 1.66 to 5.09), p<0.001) and an abnormal ECG (HR 3.10 (95% CI 1.72 to 5.57), p<0.001). The annual rate of change in LVMi was +2.77 (IQR 1.45-4.62) g/m2/year in males and +1.38 (IQR 0.09-2.85) g/m2/year in females (p<0.001). CONCLUSIONS Approximately one-quarter of patients with FD developed LVH during follow-up. Age, male sex and ECG abnormalities were associated with a higher risk of developing LVH in patients with FD.
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Affiliation(s)
- Emanuele Monda
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Napoli, Italy
- University College London, London, UK
| | | | - Robin Lachmann
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Petros Syrris
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - Giuseppe Limongelli
- Scienze Cardiotoraciche e Respiratorie, Seconda Università di Napoli, Napoli, Italy
| | - Elaine Murphy
- National Hospital for Neurology and Neurosurgery, London, UK
| | - Derralynn Hughes
- Lysosomal Storage Disorder Unit, Royal Free Hospital, London, UK
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4
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Conte E, Pizzamiglio F, Dessanai MA, Guarnieri G, Ardizzone V, Schillaci M, Dello Russo A, Casella M, Mushtaq S, Melotti E, Marchetti D, Volpato V, Drago G, Gigante C, Sforza C, Bartorelli AL, Pepi M, Pontone G, Tondo C, Andreini D. Prevalence and prognosis of structural heart disease among athletes with negative T waves and normal transthoracic echocardiography. Clin Res Cardiol 2024; 113:706-715. [PMID: 37582977 DOI: 10.1007/s00392-023-02282-5] [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: 04/08/2023] [Accepted: 07/31/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION The aim of the present study was to evaluate the prevalence and prognosis of structural heart disease (SHD) among competitive athletes with negative T waves without pathological findings at transthoracic echocardiogram. METHODS From a prospective register of 450 athletes consecutively evaluated during a second-level cardiological examination, we retrospectively identified all subjects with the following inclusion criteria: (1) not previously known cardiovascular disease; (2) negative T waves in leads other than V1-V2; (3) normal transthoracic echocardiogram. Patients underwent cardiac MRI and CT. The primary endpoint was the diagnosis of definite SHD after multimodality imaging evaluation. A follow-up was collected for a combined end-point of sudden death, resuscitated sudden cardiac death and hospitalization for any cardiovascular causes. RESULTS A total of 55 competitive athletes were finally enrolled (50 males, 90%) with a mean age of 27.5 ± 14.1 years. Among the population enrolled 16 (29.1%) athletes had a final diagnosis of SHD. At multivariate analysis, only deep negative T waves remained statistically significant [OR (95% CI) 7.81 (1.24-49.08), p = 0.0285]. Contemporary identification of deep negative T waves and complex arrhythmias in the same patients appeared to have an incremental diagnostic value. No events were collected at 49.3 ± 12.3 months of follow-up. CONCLUSIONS In a cohort of athletes with negative T waves at ECG, cardiac MRI (and selected use of cardiac CT) enabled the identification of 16 (29.1%) subjects with SHD despite normal transthoracic echocardiography. Deep negative T waves and complex ventricular arrhythmias were the only clinical characteristic associated with SHD diagnosis.
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Affiliation(s)
- Edoardo Conte
- Centro Cardiologico Monzino IRCCS, Milan, Italy.
- Department of Biomedical Science for Health, University of Milan, Milan, Italy.
| | | | | | | | | | | | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti" Ancona, Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti" Ancona, Ancona, Italy
| | | | | | | | | | | | | | - Chiarella Sforza
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | | | - Mauro Pepi
- Centro Cardiologico Monzino IRCCS, Milan, Italy
| | | | - Claudio Tondo
- Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Daniele Andreini
- Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
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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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6
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Kazum SS, Hoss S, Monakier D, Hamdan A, Kornowski R. Dynamic T-Wave Inversion: Unraveling an Athlete's Heart Mystery. JACC Case Rep 2024; 29:102186. [PMID: 38379659 PMCID: PMC10874898 DOI: 10.1016/j.jaccas.2023.102186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 02/22/2024]
Abstract
A 17-year-old athlete was initially diagnosed with presumed hypertrophic cardiomyopathy, marked by deep inferolateral T-wave inversions and mild anteroseptal hypertrophy on electrocardiogram and imaging studies. Remarkably, 6 years later, following detraining, all diagnostic signs completely resolved. This case underscores the significance of vigilant athlete follow-up.
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Affiliation(s)
- Shirit Sara Kazum
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sara Hoss
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Monakier
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ashraf Hamdan
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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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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Premature Cardiovascular Misdiagnosis of Senior Endurance-Trained Athletes. HEARTS 2023. [DOI: 10.3390/hearts4010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
A mature Caucasian patient, an endurance-trained triathlete (age group), had a routine ECG. The patient was immediately referred to Emergency based on supposed ECG abnormalities indicating a heart attack. This diagnosis was quickly dismissed based on no symptoms, heart rate of 50 BPM, athletic status, excellent health, and no prior cardiovascular problems. The patient had a history of severe white coat hypertension and underwent a further stress test and echocardiogram. The stress test showed exaggerated systolic blood pressures (over 225 mmHg) and high in-clinic basal blood pressures (160/90 mmHg), and the patient was diagnosed as hypertensive with exercise blood pressure close to stroke territory. He was told to stop racing, reduce training, and was prescribed antihypertensive drugs (which he did not take). Subsequent at-home 24 h (values close to 120/80 mmHg) and stress blood pressure measurements reversed that decision when considered in combination with an excellent echocardiogram result. The literature clearly describes endurance-trained athletes with systolic pressures over 225 mmHg Hg as being conditioned with no pathological aspects. Endurance-trained athletes should be examined as special cases in the field of cardiovascular medicine as trained physiological responses often present as cardiac abnormalities, and misdiagnosis can inappropriately change the athlete’s life.
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9
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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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10
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Gupta A, Bansal N, Jour LS, Clark BC. Utility of Exercise Stress Testing in Pediatric Patients with T-Wave Inversions. Pediatr Cardiol 2022; 43:713-718. [PMID: 34820701 DOI: 10.1007/s00246-021-02776-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 11/08/2021] [Indexed: 11/24/2022]
Abstract
T-wave inversions (TWI) in inferolateral electrocardiogram (ECG) leads (II, III, aVF, V5-V6) are often suggestive of cardiac pathology in adult patients. They are a common reason of additional testing in pediatric patients. The goal of the study is to determine correlation of exercise stress test T-wave response with diagnosis of cardiac pathology. This is a retrospective review of pediatric patients < 21 years with the finding of baseline TWI in inferior (II, III, avF) and/or lateral (V5-V6) leads on 12-lead ECG. All patients underwent treadmill exercise stress test (EST) and an echocardiogram within 1 year of each other. Demographics, baseline ECG findings, echocardiogram results, and EST data were recorded. T-wave reversion was considered complete if T waves demonstrated normalization during exercise, partial if there was minimal improvement, and no response if there was no change or worsening of inversions. In our cohort of 72 patients with a mean age 14.6 (± 2.9) years and 61% males, 59 (82%) had a structurally normal heart. Thirteen patients had evidence of structural or functional heart disease. Of the 59 patients, 83% had either complete or partial T-wave response. Among the 13 patients with heart disease, two patients had genetic testing consistent with risk for hypertrophic cardiomyopathy and had complete and partial response on EST. Exercise stress testing for TWI in pediatric patients has low sensitivity and specificity for the diagnosis of cardiac disease and routine use in this patient population may not be indicated.
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Affiliation(s)
- Aditi Gupta
- Department of Pediatrics, Lincoln Medical Center, Bronx, NY, USA
| | - Neha Bansal
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, NY, USA.,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Leslie Saint Jour
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Bradley C Clark
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, NY, USA. .,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA.
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11
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Pentikäinen H, Toivo K, Kokko S, Alanko L, Heinonen OJ, Nylander T, Selänne H, Vasankari T, Kujala UM, Villberg J, Parkkari J, Savonen K. Resting Electrocardiogram and Blood Pressure in Young Athletes and Non-Athletes: A 4-year follow-up. Clin Physiol Funct Imaging 2022; 42:200-207. [PMID: 35180329 DOI: 10.1111/cpf.12747] [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: 09/02/2021] [Accepted: 02/17/2022] [Indexed: 11/28/2022]
Abstract
A follow-up data on electrocardiogram (ECG) and blood pressure (BP) changes in adolescent athletes are scarce. We compared ECG and BP between adolescent athletes and non-athletes in a 4-year follow-up. A total of 154 youth sports clubs (SC) in Finland and 100 secondary schools for comparison data participated in this observational follow-up study. Those who maintained or adopted SC participation are referred to as "Always athletes" (n=137), those who never participated in SC as "Never athletes" (n=108) and those who dropped out of SC during the follow-up as "Changers" (n=116). The mean age of the participants was 15.5 (0.6) years in all study groups at baseline. Resting ECG including heart rate, PR interval, QRS duration, QRS axis, QRS amplitude, T axis and QT interval and BP were measured from all participants at baseline and after follow-up. "Always athletes" had lower resting heart rate, more negative T-wave axis and higher QRS amplitude than "Never athletes" at baseline and at 4-years (P < 0.05). "Changers" had lower resting heart rate, more negative T-wave axis and higher QRS amplitude, systolic BP and pulse pressure than "Never athletes" at baseline (P < 0.05). None of the observed differences at baseline, were visible at 4-years (P > 0.05) except the difference in T-wave axis (P = 0.028). The significant group x time interaction between "Changers" and "Never athletes" was found for QRS amplitude (P = 0.017). Adolescent athletes have several training-induced cardiovascular adaptations, which return towards the levels of non-athletes after cessation of regular training. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Heikki Pentikäinen
- Kuopio Research Institute of Exercise Medicine, Haapaniementie 16, FI-70100, Kuopio, Finland
| | - Kerttu Toivo
- Tampere Research Center of Sports Medicine, Ukk Institute, Tampere, Finland.,UKK Institute for Health Promotion Research, Tampere, Finland
| | - Sami Kokko
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Lauri Alanko
- Clinic for Sports and Exercise Medicine, University of Helsinki, Helsinki, Finland.,Department of Sports and Exercise Medicine, Central Finland Central Hospital, Jyvaskyla, Finland
| | - Olli J Heinonen
- Paavo Nurmi Centre & Unit for Health and Physical Activity, University of Turku, Turku, Finland
| | - Tiina Nylander
- Department of Sports and Exercise Clinic, Oulu Deaconess Institute Foundation, Oulu, Finland
| | | | - Tommi Vasankari
- UKK Institute for Health Promotion Research, Tampere, Finland
| | - Urho M Kujala
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Jari Villberg
- Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Jari Parkkari
- Tampere Research Center of Sports Medicine, Ukk Institute, Tampere, Finland.,Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland
| | - Kai Savonen
- Kuopio Research Institute of Exercise Medicine, Haapaniementie 16, FI-70100, Kuopio, Finland.,Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Kuopio, Finland
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12
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Marques JP, Freitas A, Abecasis J. Beware of regression of electrocardiographic abnormalities on detraining - It may not always mean 'athlete's heart'. Rev Port Cardiol 2021; 40:801.e1-801.e6. [PMID: 34857120 DOI: 10.1016/j.repce.2021.10.012] [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: 02/13/2018] [Accepted: 07/15/2018] [Indexed: 11/15/2022] Open
Abstract
Hypertrophic cardiomyopathy is one of the main causes of sudden cardiac death in young athletes. Differentiating between this pathological condition and 'athlete's heart' can be quite challenging, warranting a thorough clinical and imaging assessment. Clinicians often rely on detraining-induced attenuation of electrocardiographic and echocardiographic findings as a means of distinguishing between pathological and physiological cardiac remodeling. This report describes detraining-related regression of left ventricular hypertrophy in a young soccer player with a diagnosis of hypertrophic cardiomyopathy. It challenges the dogma that regression of electrocardiographic abnormalities and left ventricular hypertrophy is exclusive to physiological remodeling and questions the impact of exercise training in the phenotypic expression and progression of hypertrophic cardiomyopathy.
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Affiliation(s)
- José Pedro Marques
- Medicina Desportiva, Federação Portuguesa de Futebol; Hospital da Luz-Lisboa, Lisboa, Portugal.
| | - António Freitas
- Cardiologia, Centro de Medicina Desportiva de Lisboa, Lisboa, Portugal
| | - João Abecasis
- Departamento de Cardiologia, Hospital dos Lusíadas, Nova Medical School, Lisboa, Portugal
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13
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Marques JP, Freitas A, Abecasis J. Beware of regression of electrocardiographic abnormalities on detraining - It may not always mean 'athlete's heart'. Rev Port Cardiol 2021; 40:S0870-2551(21)00323-1. [PMID: 34389205 DOI: 10.1016/j.repc.2018.07.012] [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: 02/13/2018] [Revised: 06/01/2018] [Accepted: 07/15/2018] [Indexed: 11/22/2022] Open
Abstract
Hypertrophic cardiomyopathy is one of the main causes of sudden cardiac death in young athletes. Differentiating between this pathological condition and 'athlete's heart' can be quite challenging, warranting a thorough clinical and imaging assessment. Clinicians often rely on detraining-induced attenuation of electrocardiographic and echocardiographic findings as a means of distinguishing between pathological and physiological cardiac remodeling. This report describes detraining-related regression of left ventricular hypertrophy in a young soccer player with a diagnosis of hypertrophic cardiomyopathy. It challenges the dogma that regression of electrocardiographic abnormalities and left ventricular hypertrophy is exclusive to physiological remodeling and questions the impact of exercise training in the phenotypic expression and progression of hypertrophic cardiomyopathy.
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Affiliation(s)
- José Pedro Marques
- Medicina Desportiva, Federação Portuguesa de Futebol; Hospital da Luz-Lisboa, Lisboa, Portugal.
| | - António Freitas
- Cardiologia, Centro de Medicina Desportiva de Lisboa, Lisboa, Portugal
| | - João Abecasis
- Departamento de Cardiologia, Hospital dos Lusíadas, Nova Medical School, Lisboa, Portugal
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14
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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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15
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Inferolateral T wave inversion in athletes: phenotype-genotype correlation. Ir J Med Sci 2020; 189:1283-1287. [PMID: 32405922 DOI: 10.1007/s11845-020-02239-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/16/2020] [Indexed: 01/02/2023]
Abstract
AIMS Significant T wave inversion in young asymptomatic athletes is rare but poses a significant clinical challenge. Pre-participation sports screening programs identify such subjects. Clinical concern that such ECG changes represent an occult cardiomyopathy or forme fruste hypertrophic cardiomyopathy leads to diagnostic and therapeutic dilemma. We sought to genotype a cohort of such subjects with a normal cardiac phenotype identified in our unit over a 3-year period. METHODS Ten athletes were referred from external screening. All exhibited deep T wave inversion inferolaterally. All had negative family history for sudden death and had a normal phenotype. A panel of 133 cardiac genes were screened. RESULTS Ten male subjects with mean age of 39 years were screened. Seven had no evidence of mutations. Three subjects demonstrated variants of uncertain significance in 5 different genes: alpha-2-actinin (ACTN2), myopalladin (MYPN), the calcium channel genes CACNA1C and TRPM4 and potassium channel gene KCNQ1. The variants found have not been described in cardiomyopathies or channelopathies. At 3-year follow-up, one patient had undergone detraining, and his ECG showed complete resolution of all T wave changes. He did not have any demonstrated variants. CONCLUSIONS The absence of mutations in target genes and heterogeneous sequence variations identified in this study suggest that inferolateral T wave inversion in athletes without a phenotype may potentially represent a benign repolarization syndrome related to athletic adaptation. This was the first study to assess a phenotype-genotype correlation in this population. Further genetic studies need to be undertaken in this area.
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16
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Abstract
Cardiac repolarization of black athletes has a distinctive pattern. During an episode of pericarditis, this pattern may evolve into a "pseudonormalized" electrocardiography (ECG). On resolution of the pericardial inflammation, the ECG may return to the normal variant for a black athlete, sounding the alarms of extended disease to the myocardium. Recognizing the normal variant for a black athlete will reduce the need for unnecessary further testing or treatments. The case is discussed in detail.
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17
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Major Z, Kirschner R, Medvegy N, Kiss K, Török GM, Pavlik G, Simonyi G, Komka Z, Medvegy M. The importance of ST elevation in V 2-4 ECG leads in athletes. Physiol Int 2019. [PMID: 31847533 DOI: 10.1556/2060.106.2019.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Early repolarization in the anterior ECG leads (ERV2-4) is considered to be a sign of right ventricular (RV) remodeling, but its etiology and importance are unclear. METHODS A total of 243 top-level endurance-trained athletes (ETA; 183 men and 60 women, weekly training hours: 15-20) and 120 leisure-time athletes (LTA; 71 men and 49 women, weekly training hours: 5-6) were investigated. The ERV2-4 sign was evaluated concerning type of sport, gender, transthoracic echocardiographic parameters, and ECG changes, which can indicate elevated RV systolic pressure [left atrium enlargement (LAE), right atrium enlargement (RAE), RV conduction defect (RVcd)]. RESULTS Stroke volume and left ventricular mass were higher in ETAs vs. LTAs in both genders (p < 0.01). Prevalence of the ERV2-4 sign was significantly higher in men than in women [p = 0.000, odds ratio (OR) = 36.4] and in ETAs than in LTAs (p = 0.000). The highest ERV2-4 prevalence appeared in the most highly trained triathlonists and canoe and kayak paddlers (OR = 13.8 and 5.2, respectively). Within the ETA group, the post-exercise LAE, RAE, and RVcd changes developed more frequently in cases with than without ERV2-4 (LAE: men: p < 0.05, females: p < 0.005; RAE: men: p < 0.05, females: p < 0.005; RVcd: N.S.). These post-exercise appearing LAE, RAE, and RVcd are associated with the ERV2-4 sign (OR = 4.0, 3.7, and 3.8, respectively). CONCLUSIONS According to these results, ERV2-4 develops mainly in male ETAs due to long-lasting and repeated endurance training. The ERV2-4 sign indicates RV's adaptation to maintain higher compensatory pulmonary pressure and flow during exercise but its danger regarding malignant arrhythmias is unclear.
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Affiliation(s)
- Zs Major
- Institute of Physical Education and Sport Sciences, University of Nyíregyháza, Nyíregyháza, Hungary
| | - R Kirschner
- Department of Cardiology, Flór Ferenc Hospital of Pest County, Kistarcsa, Hungary
| | - N Medvegy
- Department of Marketing, KRKA Hungary Ltd., Budapest, Hungary
| | - K Kiss
- Department of Cardiology, Flór Ferenc Hospital of Pest County, Kistarcsa, Hungary
| | - G M Török
- Department of Cardiology, Flór Ferenc Hospital of Pest County, Kistarcsa, Hungary
| | - G Pavlik
- Department of Health Sciences and Sports Medicine, University of Physical Education, Budapest, Hungary
| | - G Simonyi
- Metabolic Center, St. Imre University Teaching Hospital, Budapest, Hungary
| | - Zs Komka
- The Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - M Medvegy
- Department of Cardiology, Flór Ferenc Hospital of Pest County, Kistarcsa, Hungary
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18
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Finocchiaro G, Sheikh N, Biagini E, Papadakis M, Maurizi N, Sinagra G, Pelliccia A, Rapezzi C, Sharma S, Olivotto I. The electrocardiogram in the diagnosis and management of patients with hypertrophic cardiomyopathy. Heart Rhythm 2019; 17:142-151. [PMID: 31349064 DOI: 10.1016/j.hrthm.2019.07.019] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Indexed: 12/20/2022]
Abstract
In an era of rapid technological development and evolving diagnostic possibilities, the electrocardiogram (ECG) is living an authentic "renaissance" in myocardial diseases. To date, the ECG remains an irreplaceable first step when evaluating patients with hypertrophic cardiomyopathy (HCM) and an abnormal ECG may be the only manifestation of disease at an early stage. In some instances, specific electrical anomalies may differentiate HCM from phenocopies such as cardiac amyloidosis and glycogen storage diseases. The exponential growth in knowledge of the complexity of HCM has led to new challenges in terms of early identification of the disease, differential diagnosis, risk stratification, and development of targeted therapies. In this scenario, the apparently "old fashioned" ECG and the array of ECG-based techniques, ranging from Holter monitoring and loop recorders to exercise testing, are as contemporary as ever. In the present review, we discuss the current role of the ECG in the diagnosis and management of HCM, focusing on various clinical settings where its appropriate use and interpretation can make a difference.
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Affiliation(s)
| | - Nabeel Sheikh
- Cardiothoracic Centre, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Elena Biagini
- Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Michael Papadakis
- Cardiology Clinical and Academic Group, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Nicolo' Maurizi
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | | | | | - Claudio Rapezzi
- Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Sanjay Sharma
- Cardiology Clinical and Academic Group, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
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19
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Al‐Saadi J, Mattsson G, Kader R, Magnusson P. Apical hypertrophic cardiomyopathy with preexcitation presenting as a myocardial infarction and ischemic stroke with a history of recurrent syncope: A case report. Clin Case Rep 2019; 7:816-820. [PMID: 30997092 PMCID: PMC6452448 DOI: 10.1002/ccr3.2104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/08/2019] [Accepted: 02/26/2019] [Indexed: 11/29/2022] Open
Abstract
Contrast-enhanced echocardiography or cardiac magnetic resonance imaging is of value in the diagnosis of apical hypertrophic cardiomyopathy. Apical hypertrophic cardiomyopathy is rare in Caucasians, and gene negativity does not rule out the diagnosis. Risk stratification for sudden cardiac death and decisions about anticoagulation in cases with atrial fibrillation should be based on guidelines.
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Affiliation(s)
- Jonathan Al‐Saadi
- Centre for Research and DevelopmentUppsala University/Region GävleborgGävleSweden
- Karolinska InstitutetStockholmSweden
| | - Gustav Mattsson
- Centre for Research and DevelopmentUppsala University/Region GävleborgGävleSweden
| | - Rozh Kader
- Centre for Research and DevelopmentUppsala University/Region GävleborgGävleSweden
- Medical University of GdanskGdanskPoland
| | - Peter Magnusson
- Centre for Research and DevelopmentUppsala University/Region GävleborgGävleSweden
- Cardiology Research Unit, Department of MedicineKarolinska InstitutetStockholmSweden
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20
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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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21
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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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22
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Yasin OZ, Rubio-Tapia A, Sarano ME. Wellens Syndrome with Syncope but Not Chest Pain. Cardiology 2016; 137:9-13. [PMID: 27951539 DOI: 10.1159/000452707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/19/2016] [Indexed: 11/19/2022]
Abstract
We report the case of a woman in her 70s presenting to the emergency department with syncope, troponemia, and an electrocardiogram with deep symmetric T-wave inversions in V2 and V3 and prolonged QTc. Her presentation was concerning for acute coronary syndrome, Wellens syndrome in particular, given the elevated troponin levels, lack of ST segment changes, and characteristic T-wave findings. The diagnosis was confirmed with angiography that showed a critical left anterior descending (LAD) artery occlusion. Since myocardial infarction does not typically present with syncope, we explored the differential diagnoses for T-wave inversions, which include electrolyte abnormalities, medications, intracranial hemorrhage, pulmonary embolism, and other cardiac diseases that were ruled out in our patient. We also explored the pathophysiology leading to syncope in the setting of acute myocardial infarction including arrhythmias and exaggerated neurally mediated response. Our patient received two drug-eluting stents to the LAD artery and was started on dual antiplatelet therapy, beta-blockers, and an angiotensin-converting enzyme inhibitor.
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Affiliation(s)
- Omar Z Yasin
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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23
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Pariente-Rodrigo E, Aguado-Antón R, Gutiérrez-Escalada B, Berlanga-Navarro L, Sgaramella G. Un electrocardiograma inquietante: ondas T negativas en precordiales izquierdas de un deportista afroamericano. Semergen 2016; 42:e79-82. [DOI: 10.1016/j.semerg.2015.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 12/15/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022]
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Interpretation of the Electrocardiogram in Athletes. Can J Cardiol 2016; 32:438-51. [DOI: 10.1016/j.cjca.2015.10.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 10/16/2015] [Accepted: 10/20/2015] [Indexed: 01/02/2023] Open
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Walsh BM, Smith SW. "Persistent Juvenile" T-Wave Pattern May Not Be Persistent: Case Series and Literature Review. J Emerg Med 2015; 49:e165-72. [PMID: 26409676 DOI: 10.1016/j.jemermed.2015.06.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 06/24/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND T-wave inversions (TWI) can signify serious pathology, but may also represent a benign variant. One such variant has been termed the "persistent juvenile" T-wave pattern (PJTWP). It is characterized by TWI in the right precordium, and has been understood to represent an arrested stage of the normal electrocardiographic evolution from childhood. CASE REPORT A series of four African-American (AA) women, ages 20 to 43 years, presented to the Emergency Department, and were found to have right precordial TWI that was absent on prior electrocardiograms. The diagnostic evaluation did not reveal acute cardiopulmonary causes for these new TWIs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The "persistent" juvenile pattern may not be actually persistent in the individual patient. In an appropriate patient, such as a young AA woman, where acute cardiopulmonary disease has been reasonably ruled out, the finding of new right precordial TWI should not preclude the diagnosis of PJTWP.
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Affiliation(s)
- Brooks M Walsh
- Department of Emergency Medicine, Bridgeport Hospital, Bridgeport, Connecticut
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center, University of Minnesota School of Medicine, Minneapolis, Minnesota
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Wilson MG, Carré F. What's the big deal about T-wave inversion in athletes? A guide to clinical interpretation. Br J Sports Med 2015; 50:72-3. [DOI: 10.1136/bjsports-2015-094636] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2015] [Indexed: 11/04/2022]
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Jacob D, Main ML, Gupta S, Gosch K, McCoy M, Magalski A. Prevalence and significance of isolated T wave inversion in 1755 consecutive American collegiate athletes. J Electrocardiol 2015; 48:407-14. [PMID: 25795567 DOI: 10.1016/j.jelectrocard.2015.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND We evaluated the prevalence of isolated T-wave inversions (TWI) in American athletes using contemporary ECG criteria. Ethnic and gender disparities including the association of isolated TWI with underlying abnormal cardiac structure are evaluated. METHODS From 2004 to 2014, 1755 collegiate athletes at a single American university underwent prospective collection of medical history, physical examination, 12-lead ECG, and 2-dimensional echocardiography. ECG analysis was performed to evaluate for isolated TWI as per contemporary ECG criteria. RESULTS The overall prevalence of isolated TWI is 1.3%. Ethnic and gender disparities are not observed in American athletes (black vs. white: 1.7% vs. 1.1%; p=0.41) (women vs. men: 1.5% vs. 1.1; p=0.52). No association was found with underlying cardiomyopathy. CONCLUSION A lower prevalence of isolated TWI in American athletes than previously reported. Isolated TWI was not associated with an abnormal echocardiogram. No ethnic or gender disparity is seen in American college athletes.
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Affiliation(s)
- Dany Jacob
- University of Missouri-Kansas City, 2301 Holmes St, Kansas City, MO, USA
| | - Michael L Main
- Saint Luke's Mid America Heart Institute, 4401 Wornwall Rd, Kansas City, MO, USA
| | - Sanjaya Gupta
- Saint Luke's Mid America Heart Institute, 4401 Wornwall Rd, Kansas City, MO, USA
| | - Kensey Gosch
- Saint Luke's Mid America Heart Institute, 4401 Wornwall Rd, Kansas City, MO, USA
| | - Marcia McCoy
- Saint Luke's Mid America Heart Institute, 4401 Wornwall Rd, Kansas City, MO, USA
| | - Anthony Magalski
- Saint Luke's Mid America Heart Institute, 4401 Wornwall Rd, Kansas City, MO, USA.
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Schnell F, Riding N, O’Hanlon R, Axel Lentz P, Donal E, Kervio G, Matelot D, Leurent G, Doutreleau S, Chevalier L, Guerard S, Wilson MG, Carré F. Recognition and Significance of Pathological T-Wave Inversions in Athletes. Circulation 2015; 131:165-73. [DOI: 10.1161/circulationaha.114.011038] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background—
Pathological T-wave inversion (PTWI) is rarely observed on the ECG of healthy athletes, whereas it is common in patients with certain cardiac diseases. All ECG interpretation guidelines for use within athletes state that PTWI (except in leads aVR, III and V1 and in V1–V4 when preceded by domed ST segment in asymptomatic Afro-Caribbean athletes only) cannot be considered a physiological adaptation. The aims of the present study were to prospectively determine the prevalence of cardiac pathology in athletes presenting with PTWI, and to examine the efficacy of cardiac magnetic resonance in the work-up battery of further examinations.
Methods and Results—
Athletes presenting with PTWI (n=155) were investigated with clinical examination, ECG, echocardiography, exercise testing, 24h Holter ECG, and cardiac magnetic resonance. Cardiac disease was established in 44.5% of athletes, with hypertrophic cardiomyopathy (81%) the most common pathology. Echocardiography was abnormal in 53.6% of positive cases, and cardiac magnetic resonance identified a further 24 athletes with disease. Five athletes (7.2%) considered normal on initial presentation subsequently expressed pathology during follow-up. Familial history of sudden cardiac death and ST-segment depression associated with PTWI were predictive of cardiac disease.
Conclusions—
PTWI should be considered pathological in all cases until proven otherwise, because it was associated with cardiac pathology in 45% of athletes. Despite echocardiography identifying pathology in half of these cases, cardiac magnetic resonance must be considered routine in athletes presenting with PTWI with normal echocardiography. Although exclusion from competitive sport is not warranted in the presence of normal secondary examinations, annual follow-up is essential to ascertain possible disease expression.
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Affiliation(s)
- Frédéric Schnell
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
| | - Nathan Riding
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
| | - Rory O’Hanlon
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
| | - Pierre Axel Lentz
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
| | - Erwan Donal
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
| | - Gaelle Kervio
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
| | - David Matelot
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
| | - Guillaume Leurent
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
| | - Stéphane Doutreleau
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
| | - Laurent Chevalier
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
| | - Sylvain Guerard
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
| | - Mathew G. Wilson
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
| | - François Carré
- From the Department of Physiology, Rennes1 University, Rennes France (F.S., F.C.); the Department of Sport Medicine, Pontchaillou Hospital, Rennes, France (F.S., F.C.); INSERM UMR 1099, Rennes France (F.S., E.D., G.K., D.M., F.C.); the Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar (N.R., M.G.W.); the Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland (R.O.); the Department of Radiology, Pontchaillou Hospital, Rennes
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Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, Limongelli G, Mahrholdt H, McKenna WJ, Mogensen J, Nihoyannopoulos P, Nistri S, Pieper PG, Pieske B, Rapezzi C, Rutten FH, Tillmanns C, Watkins H. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J 2014; 35:2733-79. [PMID: 25173338 DOI: 10.1093/eurheartj/ehu284] [Citation(s) in RCA: 2894] [Impact Index Per Article: 289.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
MESH Headings
- Ablation Techniques/methods
- Adult
- Angina Pectoris/etiology
- Arrhythmias, Cardiac/etiology
- Cardiac Imaging Techniques/methods
- Cardiac Pacing, Artificial/methods
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/etiology
- Cardiomyopathy, Hypertrophic/therapy
- Child
- Clinical Laboratory Techniques/methods
- Death, Sudden, Cardiac/prevention & control
- Delivery of Health Care
- Diagnosis, Differential
- Electrocardiography/methods
- Female
- Genetic Counseling/methods
- Genetic Testing/methods
- Heart Failure/etiology
- Heart Valve Diseases/diagnosis
- Heart Valve Diseases/therapy
- Humans
- Medical History Taking/methods
- Pedigree
- Physical Examination/methods
- Preconception Care/methods
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Complications, Cardiovascular/therapy
- Prenatal Care/methods
- Risk Factors
- Sports Medicine
- Syncope/etiology
- Thoracic Surgical Procedures/methods
- Ventricular Outflow Obstruction/etiology
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Zhang L, Liu L, Kowey PR, Fontaine GH. The electrocardiographic manifestations of arrhythmogenic right ventricular dysplasia. Curr Cardiol Rev 2014; 10:237-45. [PMID: 24827798 PMCID: PMC4040875 DOI: 10.2174/1573403x10666140514102928] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 06/10/2013] [Accepted: 01/28/2014] [Indexed: 01/21/2023] Open
Abstract
The ECG is abnormal in most patients with arrhythmogenic right ventricular dysplasia (ARVD). Right ventricular parietal block, reduced QRS amplitude, epsilon wave, T wave inversion in V1-3 and ventricular tachycardia in the morphology of left bundle branch block are the characteristic changes that reflect the underlying genetic predetermined pathology and pathoelectrophysiology. Recognizing the characteristic ECG changes in ARVD will be of help in making a correct diagnosis of this rare disease.
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Affiliation(s)
| | | | | | - Guy H Fontaine
- Lankenau Medical Center & Lankenau Institute for Medical Research, 558 MOB East, 100 Lancaster Avenue, Wynnewood, PA 19096, USA.
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32
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Chen X, Zhao T, Lu M, Yin G, Xiangli W, Jiang S, Prasad S, Zhao S. The relationship between electrocardiographic changes and CMR features in asymptomatic or mildly symptomatic patients with hypertrophic cardiomyopathy. Int J Cardiovasc Imaging 2014; 30 Suppl 1:55-63. [PMID: 24723003 DOI: 10.1007/s10554-014-0416-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 04/01/2014] [Indexed: 01/01/2023]
Abstract
To investigate the relationship between electrocardiographic (ECG) abnormalities and left ventricular (LV) segmental hypertrophy and myocardial fibrosis assessed by cardiovascular magnetic resonance (CMR) in asymptomatic or mildly symptomatic patients with hypertrophic cardiomyopathy (HCM). 118 asymptomatic or mildly symptomatic patients with HCM were examined with late gadolinium enhancement (LGE) CMR, 12-lead ECG, and echocardiography. The distribution and magnitude of LV segmental hypertrophy and LGE were assessed and analyzed in relation to ECG abnormalities. Abnormal electrocardiograms were found in 113 of 118 (95%) patients. Negative T waves were associated with greater apical septal thickness (P = 0.009) and an increased ratio of LV septum to free wall thickness (P = 0.01). Giant negative T waves (GNT) were found in 19 patients (16%), and were associated with apical HCM (P < 0.001), greater apical thickness (P = 0.004), and increased ratio of LV apical to basal wall thickness (P < 0.001). However, no significant association was demonstrated between GNT and apical LGE (P = 0.71). Abnormal Q waves were associated with greater basal anteroseptal thickness (P = 0.001), maximal basal thickness (P = 0.004), and more segments with extensive LGE (>75% wall thickness involved) (P = 0.001). LV hypertrophy was related to greater LV mass (P = 0.002) and LV end diastolic volume (P = 0.002). In addition, a modest but significant correlation was observed between maximum LV wall thickness and the Romhilt-Estes score (r = 0.41, P < 0.001). GNT were associated with apical HCM and an increased ratio of LV apical to basal wall thickness. Abnormal Q waves were related to basal anteroseptal hypertrophy and segmental extensive LGE.
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Affiliation(s)
- Xiuyu Chen
- Department of Radiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, 167 Beilishi Road, Xi Cheng District, Beijing, 100037, China
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33
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Pérez-Riera AR, de Lucca AA, Barbosa-Barros R, Yanowitz FG, de Cano SF, Cano MN, Palandri-Chagas AC. Value of electro-vectorcardiogram in hypertrophic cardiomyopathy. Ann Noninvasive Electrocardiol 2014; 18:311-26. [PMID: 23879271 DOI: 10.1111/anec.12067] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The electrocardiogram is an important tool for the initial diagnostic suspicion of hypertrophic cardiomyopathy in any of its forms, both in symptomatic and in asymptomatic patients because it is altered in more than 90 percent of the cases. Electrocardiographic anomalies are more common in patients carriers of manifest hypertrophic cardiomyopathy and the electrocardiogram alterations are earlier and more sensitive than the increase in left ventricular wall thickness detected by the echocardiogram. Nevertheless, despite being the leading cause of sudden death among young competitive athletes there is no consensus over the need to include the method in the pre-participation screening. In apical hypertrophic cardiomyopathy the electrocardiographic hallmarks are the giant negative T waves in anterior precordial leads. In the vectorcardiogram, the QRS loop is located predominantly in the left anterior quadrant and T loop in the opposite right posterior quadrant, which justifies the deeply negative T waves recorded. The method allows estimating the left ventricular mass because it relates to the maximal spatial vector voltage of the left ventricle in the QRS loop. The recording on electrocardiogram or Holter monitoring of nonsustained monomorphic ventricular tachycardia in patients with syncope, recurrent syncope in young patient, hypotension induced by strain, bradyarrhythmia, or concealed conduction are markers of poor prognosis. The presence of rare sustained ventricular tachycardia is observed in mid-septal obstructive HCM with apical aneurysm. The presence of complete right bundle branch block pattern is frequent after the percutaneous treatment and complete left bundle branch block is the rule after myectomy.
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Chen X, Zhao S, Zhao T, Lu M, Yin G, Jiang S, Prasad S. T-wave inversions related to left ventricular basal hypertrophy and myocardial fibrosis in non-apical hypertrophic cardiomyopathy: A cardiovascular magnetic resonance imaging study. Eur J Radiol 2014; 83:297-302. [DOI: 10.1016/j.ejrad.2013.10.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 09/24/2013] [Accepted: 10/25/2013] [Indexed: 01/19/2023]
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Abstract
Use of medications for attention-deficit hyperkinetic disorder and preparticipation sports physical examination has led to an increase in number of electrocardiograms (ECG) performed during adolescence. Interpreting ECGs in children and young adults must take into account the evolutionary changes with age and the benign variants, which are usually not associated with heart disease. It is crucial for primary-care providers to recognize the changes on ECG associated with heart disease and risk of sudden death. In this article, the significance, sensitivity, specificity, and the diagnostic workup of these findings in the asymptomatic teenager are discussed.
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Affiliation(s)
- Harinder R Singh
- Division of Cardiology, The Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubein, Detroit, MI 48201, USA.
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36
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Riding NR, Sharma S, Salah O, Khalil N, Carré F, George KP, Hamilton B, Chalabi H, Whyte GP, Wilson MG. Systematic echocardiography is not efficacious when screening an ethnically diverse cohort of athletes in West Asia. Eur J Prev Cardiol 2013; 22:263-70. [PMID: 24057688 DOI: 10.1177/2047487313506549] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The clinical and economic value of including systematic echocardiography (ECHO) alongside the 12-lead electrocardiograpm (ECG) when undertaking pre-participation screening in athletes has not been examined, yet several sporting organistations recommend its inclusion. DESIGN To examine the efficacy of systematic ECHO alongside the ECG, to identify sudden cardiac death (SCD) disease and to provide a cost-analysis of a government-funded pre-participation screening programme. METHODS A total 1628 athletes presented for cardiological consultation, ECG, and ECHO as standard, with further cardiac examinations performed if necessary to confirm or exclude pathology. The efficacy of systematic ECHO was compared to an ECG-led programme, with ECHO reserved as a follow-up examination. RESULTS To screen 1628 athletes with ECG and ECHO cost US$743,996. There were 54 24-h-blood pressure/ECG Holter recordings, 62 exercise tests, 25 CMRs, two electrophysiological studies, and two genetic tests, which cost US$67,734: total US$811,730. Eight athletes (0.5%) were identified with hypertrophic cardiomyopathy (HCM) and two (0.1%) with Wolff-Parkinson-White syndrome. The cost per identifed athlete was US$81,173. All 10 athletes presented an abnormal ECG. No athlete diagnosed with HCM was identified by ECHO in isolation. When adopting a ECG-led screening protocol, 15% of athletes required ECHO as a follow-up examination, resulting in a US$380,600 cost reduction (47% saving), with the cost per diagnosis reduced to US$43,113. CONCLUSIONS Athletes diagnosed with a disease associated with SCD were identified via an abnormal ECG and/or physical examination, personal symptoms, or family history. Screening athletes with systematic ECHO is not economically or clinically effective.
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Affiliation(s)
- Nathan R Riding
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar Research Institute for Sport and Exercise Science, Liverpool John Moores University, UK
| | - Sanjay Sharma
- Department of Cardiovascular Sciences, St Georges University of London, UK
| | - Othman Salah
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Nelly Khalil
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - François Carré
- Rennes 1 University, Pontchaillou Hospital, INSERM U 642, France
| | - Keith P George
- Research Institute for Sport and Exercise Science, Liverpool John Moores University, UK
| | - Bruce Hamilton
- Sports Medicine Department, HPSNZ, Millennium Centre, Mairangi Bay, Auckland, New Zealand
| | - Hakim Chalabi
- CMOs Office, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Gregory P Whyte
- Research Institute for Sport and Exercise Science, Liverpool John Moores University, UK
| | - Mathew G Wilson
- Department of Sports Medicine, ASPETAR, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
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37
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Dzendrowskyj P, Hamilton B, Wilson MG. Differentiating athlete's heart from inherited cardiac pathology: the challenge of repolarisation abnormalities presenting during anaesthesia. Anaesth Intensive Care 2013; 41:256-60. [PMID: 23530794 DOI: 10.1177/0310057x1304100216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This case report describes an asymptomatic healthy male professional athlete who underwent general anaesthesia for a routine orthopaedic operation. Peri-procedure, pronounced ST elevation suggestive of myocardial ischaemia manifested on the electrocardiogram lasting for four hours post-procedure, upon which the athlete developed deep and diffuse inferolateral T-wave inversion. These changes resolved spontaneously and the patient remained clinically stable throughout. This case demonstrates the clinical conundrum facing anaesthetists attempting to differentiate between repolarisation anomalies that are commonly observed in high-level athletes and those of inherited cardiac pathology, namely hypertrophic cardiomyopathy, which is the leading cause of sudden cardiac death in young athletes.
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Affiliation(s)
- P Dzendrowskyj
- Department of Anaesthesia, Qatar Orthopaedic and Sports Medicine Hospital, Doha, Qatar.
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