Prevalence of Cardiomyopathy in Italian Asymptomatic Children With Electrocardiographic T-Wave Inversion at Preparticipation Screening

Diagnostic cost-effectiveness of a two-stage cardiovascular evaluation program in young-adolescent athletes. Role of echocardiography

BACKGROUND

Sports medical examinations are a tool to detect potentially life-threatening situations during physical activity, but their usefulness and protocols in young athletes remain controversial. The aim was to describe the diagnostic performance of a 2-step ECG and echocardiogram screening model in a large sample of healthy young-adolescent athletes (aged 11-16 years), evaluating its cost-effectiveness for cardiovascular disease (CVD) detection.

METHODS

Cross-sectional study of 2617 individuals (81 % male, mean age 15 years), over 20 federated sports (La Rioja-Spain). A cardiological examination included family and personal history, physical examination, ECG, and transthoracic echocardiogram. The previous ECG, conducted at 11-13 years old, was reviewed in 1589 individuals (60 %). ECGs were interpreted according to 2017 international criteria. The prevalence of structural cardiac disease (CD) was investigated, and the diagnostic performance of both tests and the cost of screening was evaluated.

RESULTS

CVD was diagnosed in 63 athletes (2.4 %) and 16 (0.6 %) with pathology related to sudden cardiac death (SCD). In 3 cases (0.11 %), cessation of sporting activity was indicated, and in 2 cases (0.07 %) treatment for congenital CD was indicated. ECG alterations were infrequent (2.5 %). Eighty percent of the structural CD diagnosed by echocardiogram had a normal ECG. The cost per CVD detected was €3,080, and for CVD associated with SCD, it was €12,323.

CONCLUSIONS

Our study shows the diagnostic cost-effectiveness of a two-step cardiac screening protocol, including ECG, and highlights the role of echocardiography in young adolescent athletes, which could be implemented at a low and reasonable cost.

Proposed diagnostic criteria for arrhythmogenic cardiomyopathy: European Task Force consensus report

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.

Association of T-wave electrocardiogram changes and type 2 diabetes: a cross-sectional sub-analysis of the MASHAD cohort population using the Minnesota coding system

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) has become a major health concern with an increasing prevalence and is now one of the leading attributable causes of death globally. T2DM and cardiovascular disease are strongly associated and T2DM is an important independent risk factor for ischemic heart disease. T-wave abnormalities (TWA) on electrocardiogram (ECG) can indicate several pathologies including ischemia. In this study, we aimed to investigate the association between T2DM and T-wave changes using the Minnesota coding system.

METHODS

A cross-sectional study was conducted on the MASHAD cohort study population. All participants of the cohort population were enrolled in the study. 12-lead ECG and Minnesota coding system (codes 5-1 to 5-4) were utilized for T-wave observation and interpretation. Regression models were used for the final evaluation with a level of significance being considered at p < 0.05.

RESULTS

A total of 9035 participants aged 35-65 years old were included in the study, of whom 1273 were diabetic. The prevalence of code 5-2, 5-3, major and minor TWA were significantly higher in diabetics (p < 0.05). However, following adjustment for age, gender, and hypertension, the presence of TWAs was not significantly associated with T2DM (p > 0.05). Hypertension, age, and body mass index were significantly associated with T2DM (p < 0.05).

CONCLUSIONS

Although some T-wave abnormalities were more frequent in diabetics, they were not statistically associated with the presence of T2DM in our study.

Inherited Arrhythmias in the Pediatric Population: An Updated Overview

Pediatric cardiomyopathies (CMs) and electrical diseases constitute a heterogeneous spectrum of disorders distinguished by structural and electrical abnormalities in the heart muscle, attributed to a genetic variant. They rank among the main causes of morbidity and mortality in the pediatric population, with an annual incidence of 1.1-1.5 per 100,000 in children under the age of 18. The most common conditions are dilated cardiomyopathy (DCM) and hypertrophic cardiomyopathy (HCM). Despite great enthusiasm for research in this field, studies in this population are still limited, and the management and treatment often follow adult recommendations, which have significantly more data on treatment benefits. Although adult and pediatric cardiac diseases share similar morphological and clinical manifestations, their outcomes significantly differ. This review summarizes the latest evidence on genetics, clinical characteristics, management, and updated outcomes of primary pediatric CMs and electrical diseases, including DCM, HCM, arrhythmogenic right ventricular cardiomyopathy (ARVC), Brugada syndrome (BrS), catecholaminergic polymorphic ventricular tachycardia (CPVT), long QT syndrome (LQTS), and short QT syndrome (SQTS).

Electrocardiographic findings in pediatric versus young-adolescent athletes: A comparative analysis using general international criteria

BACKGROUND

The inclusion of electrocardiogram (ECG) in medical examinations for sports practice serves as a valuable tool for identifying potential life-threatening conditions during physical exercise. However, its applicability in young individuals remains a subject of controversy, primarily due to relatively high rates of false positives and the associated costs of further investigations. Furthermore, the validation of International Criteria for athletes below 12 years of age in optimizing pre-participation screening for young athletes is yet to be established. In light of these considerations, this study aims to describe the prevalence of ECG findings in a sample of children and young-adolescent athletes aged 11-16 years, employing refined Seattle interpretation criteria. Additionally, we seek to compare these findings based on age group and sex.

METHODS

This was a retrospective and observational study of 3747 athletes 11-16 year-olds. Evaluation included interviewer-administered questionnaires for relevant history, physical examination and resting 12 - lead ECG for each participant. The primary outcome measure was abnormal ECG findings according to the International Recommendations for Electrocardiographic Interpretation in Athletes.

RESULTS

Among the evaluated population of pediatric and young adolescent athletes (77.5% boys; >99% Caucasian), the vast majority exhibited normal electrocardiogram (ECG) results, with adaptive findings related to sports participation being more frequent among young adolescents and males. The presence of significant ECG abnormalities in young-adolescent athletes was uncommon (2.05%; 1.92% children and 2.32% young-adolescent) and required additional examinations. 0.27% of the total population were diagnosed with a previously unknown cardiac pathology only through the ECG.

CONCLUSIONS

This study provides valuable insights into the prevalence of normal, borderline, and abnormal electrocardiogram (ECG) findings in a large population of pediatric and young-adolescent athletes. These findings serve as guidance in detecting potentially serious cardiac alterations within this specific group, considering variations based on age and sex. The study confirms that ECG screening is a useful tool for identifying cardiac abnormalities in pediatric and young-adolescent athletes, even though the prevalence of significant findings in this population is relatively low. Furthermore, our findings support the utilization of the refined Seattle criteria as a sensitive and specific technique for screening pediatric and young-adolescent athletes, further enhancing the accuracy of ECG-based evaluations.

The Role of Genetics in the Management of Heart Failure Patients

Over the last decades, the relevance of genetics in cardiovascular diseases has expanded, especially in the context of cardiomyopathies. Its relevance extends to the management of patients diagnosed with heart failure (HF), given its capacity to provide invaluable insights into the etiology of cardiomyopathies and identify individuals at a heightened risk of poor outcomes. Notably, the identification of an etiological genetic variant necessitates a comprehensive evaluation of the family lineage of the affected patients. In the future, these genetic variants hold potential as therapeutic targets with the capability to modify gene expression. In this complex setting, collaboration among cardiologists, specifically those specializing in cardiomyopathies and HF, and geneticists becomes paramount to improving individual and family health outcomes, as well as therapeutic clinical results. This review is intended to offer geneticists and cardiologists an updated perspective on the value of genetic research in HF and its implications in clinical practice.

Sudden cardiac arrest in athletes and strategies to optimize preparedness

Sudden cardiac arrest (SCA) is the leading cause of death in young athletes. Despite efforts to improve preparedness for cardiac emergencies, the incidence of out-of-hospital cardiac arrests in athletes remains high, and bystander awareness and readiness for SCA support are inadequate. Initiatives such as designing an emergency action plan (EAP) and mandating training in cardiopulmonary resuscitation (CPR) and automated external defibrillator use (AED) for team members and personnel can contribute to improved survival rates in SCA cases. This review provides an overview of SCA in athletes, focusing on identifying populations at the highest risk and evaluating the effectiveness of different screening practices in detecting conditions that may lead to SCA. We summarize current practices and recommendations for improving the response to SCA events, and we highlight the need for ongoing efforts to optimize preparedness through the implementation of EAPs and the training of individuals in CPR and AED use. Additionally, we propose a call to action to increase awareness and training in EAP development, CPR, and AED use for team members and personnel. To improve outcomes of SCA cases in athletes, it is crucial to enhance bystander awareness and preparedness for cardiac emergencies. Implementing EAPs and providing training in CPR and AED use for team members and personnel are essential steps toward improving survival rates in SCA cases.

Desmosomal Arrhythmogenic Cardiomyopathy: The Story Telling of a Genetically Determined Heart Muscle Disease

The history of arrhythmogenic cardiomyopathy (AC) as a genetically determined desmosomal disease started since the original discovery by Lancisi in a four-generation family, published in 1728. Contemporary history at the University of Padua started with Dalla Volta, who haemodynamically investigated patients with "auricularization" of the right ventricle, and with Nava, who confirmed familiarity. The contemporary knowledge advances consisted of (a) AC as a heart muscle disease with peculiar electrical instability of the right ventricle; (b) the finding of pathological substrates, in keeping with a myocardial dystrophy; (c) the inclusion of AC in the cardiomyopathies classification; (d) AC as the main cause of sudden death in athletes; (e) the discovery of the culprit genes coding proteins of the intercalated disc (desmosome); (f) progression in clinical diagnosis with specific ECG abnormalities, angiocardiography, endomyocardial biopsy, 2D echocardiography, electron anatomic mapping and cardiac magnetic resonance; (g) the discovery of left ventricular AC; (h) prevention of SCD with the invention and application of the lifesaving implantable cardioverter defibrillator and external defibrillator scattered in public places and playgrounds as well as the ineligibility for competitive sport activity for AC patients; (i) genetic screening of the proband family to unmask asymptomatic carriers. Nondesmosomal ACs, with a phenotype overlapping desmosomal AC, are also treated, including genetics: Transmembrane protein 43, SCN5A, Desmin, Phospholamban, Lamin A/C, Filamin C, Cadherin 2, Tight junction protein 1.

Cardiomyopathies in children: An overview

Paediatric cardiomyopathies form a heterogeneous group of disorders characterized by structural and electrical abnormalities of the heart muscle, commonly due to a gene variant of the myocardial cell structure. Mostly inherited as a dominant or occasionally recessive trait, they might be part of a syndromic disorder of underlying metabolic or neuromuscular defects or combine early developing extracardiac abnormalities (i.e., Naxos disease). The annual incidence of 1 per 100,000 children appears higher during the first two years of life. Dilated and hypertrophic cardiomyopathy phenotypes share an incidence of 60% and 25%, respectively. Arrhythmogenic right ventricular cardiomyopathy (ARVC), restrictive cardiomyopathy, and left ventricular noncompaction are less commonly diagnosed. Adverse events such as severe heart failure, heart transplantation, or death usually appear early after the initial presentation. In ARVC patients, high-intensity aerobic exercise has been associated with worse clinical outcomes and increased penetrance in at-risk genotype-positive relatives. Acute myocarditis in children has an incidence of 1.4-2.1 cases/per 100,000 children per year, with a 6-14% mortality rate during the acute phase. A genetic defect is considered responsible for the progression to dilated cardiomyopathy phenotype. Similarly, a dilated or arrhythmogenic cardiomyopathy phenotype might emerge with an episode of acute myocarditis in childhood or adolescence. This review provides an overview of childhood cardiomyopathies focusing on clinical presentation, outcome, and pathology.

Protecting the stars of tomorrow: do international cardiovascular preparticipation screening policies account for the paediatric athlete? A systematic review and quality appraisal

OBJECTIVE

(1) Identify and review current policies for the cardiovascular screening of athletes to assess their applicability to the paediatric population and (2) evaluate the quality of these policy documents using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool.

DESIGN

Systematic review and quality appraisal of policy documents.

DATA SOURCES

A systematic search of PubMed, MEDLINE, Scopus, Web of Science, SportDiscus and CINAHL.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

An article was included if it was a policy/position statement/guideline/consensus or recommendation paper relating to athletes and cardiovascular preparticipation screening.

RESULTS AND SUMMARY

Of the 1630 articles screened, 13 met the inclusion criteria. Relevance to paediatric athletes was found to be high in 3 (23%), moderate in 6 (46%) and low in 4 (31%), and only 2 provide tailored guidance for the athlete aged 12-18 years. A median 5 related citations per policy investigated solely paediatric athletes, with study designs most commonly being retrospective (72%). AGREEII overall quality scores ranged from 25% to 92%, with a median of 75%. The lowest scoring domains were rigour of development; (median 32%) stakeholder involvement (median 47%) and Applicability (median 52%).

CONCLUSION

Cardiac screening policies for athletes predominantly focus on adults, with few providing specific recommendations for paediatric athletes. The overall quality of the policies was moderate, with more recent documents scoring higher. Future research is needed in paediatric athletes to inform and develop cardiac screening guidelines, to improve the cardiac care of youth athletes.

The juvenile ECG pattern in adolescent athletes and non-athletes in a national cardiac screening program (BEAT-IT)

BACKGROUND

Anterior T wave inversion (TWI) is frequent in healthy adolescent individuals (juvenile ECG pattern), normalising after puberty. Its clinical implications are uncertain.

AIM

This study assessed a) national prevalence of anterior TWI, b) ST segment morphology, c) proportion of individuals with a juvenile ECG pattern whose ECG normalises and d) factors predicting TWI persistence >16 years.

METHODS

Adolescents (mean 15y) in Malta were systematically invited to enrol in a cardiac screening program. Subjects completed a health questionnaire and an ECG at their school. Participants with TWI were labelled as TWI in V₁-V₂ or extended TWI (V₁-V₃/₄). The latter were followed at 1 year with a repeat ECG. Those with persistent extended anterior TWI were offered evaluation and surveillance.

RESULTS

The prevalence of isolated anterior TWI was 5.0%, commoner in females (6.3%) independent of athletic ability. Extended TWI was commoner in female athletes (4.2%, non-athletes 2.1%). Females often had shallow TWI without overt ST segment abnormalities. Deep TWI and ST segment changes were more frequent in males. Only 0.2% of cases persisted ≥16 years of age. ST segment characteristics were not able to predict T wave normalisation. No events took place during follow up (40 ± 9 months).

CONCLUSION

Anterior TWI is a frequent phenomenon in adolescents, especially in females. Female athletes are also more likely to have extended anterior TWI. Only 0.2% of cases have persistent anterior TWI at 16 years of age. Chest wall anatomy may explain this phenomenon in females. It is uncommon in males, hence why surveillance is more prudent.

Electrocardiographic changes in non-hospitalised children with COVID-19

OBJECTIVES

Many children diagnosed with COVID-19 infections did not require hospitalisation. Our objective was to analyse electrocardiographic changes in children with asymptomatic, mild or moderate COVID-19 who did not require hospitalisation.

METHODS

All children are seen in a paediatric cardiology clinic who had asymptomatic, mild or moderate COVID-19 that did not require hospitalisation and had at least one electrocardiogram after their diagnosis were included in this retrospective analysis. Records were reviewed to determine COVID-19 disease severity and presence of Long COVID. Rhythm assessment, atrial enlargement, ventricular hypertrophy, PR/QRS/QT interval duration and ST-T wave abnormalities were analysed by a paediatric electrophysiologist. Clinically ordered echocardiograms were reviewed for signs of myopericarditis (left ventricular ejection fraction and pericardial effusion) on any subject with an electrocardiographic abnormality.

RESULTS

Of the 82 children meeting inclusion criteria (14.4 years, range 1-18 years, 57% male), 17 patients (21%) demonstrated electrocardiographic changes. Ten patients (12%) had electrocardiogram of borderline significance, which included isolated mild PR prolongation or mild repolarisation abnormalities. The other seven patients (9%) had concerning electrocardiographic findings consisting of more significant repolarisation abnormalities. None of the patients with an abnormal electrocardiogram revealed any echocardiographic abnormality. All abnormal electrocardiograms normalised over time except in two cases. Across the entire cohort, greater COVID-19 disease severity and long COVID were not associated with electrocardiographic abnormalities.

CONCLUSIONS

Electrocardiographic abnormalities are present in a minority of children with an asymptomatic, mild or moderate COVID-19 infection. Many of these changes resolved over time and no evidence of myopericarditis was present on echocardiography.

Utility of Exercise Stress Testing in Pediatric Patients with T-Wave Inversions

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.

Age-Related Electrocardiographic Characteristics of Male Junior Soccer Athletes

Introduction

Very limited data exist on normal age-related ECG variations in adolescents and no data have been published regarding the ECG anomalies induced by intensive training, which are relevant in pre-participation screening for sudden cardiac death prevention in the adolescent athletic population. The purpose of this study was to establish normal age-related electrocardiographic measurements (P wave duration, PR interval, QRS duration, QT, and QTc interval) grouped according to 2-year age intervals.

Methods

A total of 2,151 consecutive healthy adolescent Soccer athletes (trained for a mean of 7.2 ± 1.1 h per week, 100% male Caucasians, mean age 12.4 ± 1.4 years, range 7–18) underwent pre-participation screening, which included ECG and transthoracic echocardiography in a single referral center.

Results

Their heart rate progressively slowed as age increased (p < 0.001, ranging from 80.8 ± 13.2 to 59.5 ± 10.2 bpm), as expected. The P wave, PR interval, and QRS duration significantly increased in older age classes (p = 0.019, p = 0.001, and p < 0.001, respectively), and after Bonferroni's correction, the difference remained significant in all age classes for QRS duration. The QTc interval diminished progressively with increasing age (p = 0.003) while the QT interval increased progressively (p < 0.001).

Conclusions

Significant variations in the normal ECG characteristics of young athletes exist between different age groups related to increasing age and training burden, thus, age-specific reference values could be adopted, as already done for echocardiographic measurements, and may help to further discriminate potentially pathologic conditions.

An idiopathic case of precordial deep T-wave inversion

Introduction and importance

One percent of the patients referred to cardiac intensive care unit (CICU) are presented with T-wave inversion.

Case presentation

We present a case of 78-year-old woman with chest pain and dyspnea. ECG showed precordial deep T-wave inversion.

Clinical discussion

Cardiomyopathies, ischemia and other pathologies were ruled out.

Conclusion

It is likely to be a first reported case of idiopathic deep T-wave inversion seen in the family without any cardiac or non-cardiac etiology.

•

T-wave inversion is commonly presented in electrocardiogram (ECG) of infants.

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Precordial lead T-wave inversion is seen in infants and can be seen in childhood period as well.

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Familial clustering of this type of ECG was attractive.

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Genetic analysis of these findings can give more meaningful conclusions.

Evolving Diagnostic Criteria for Arrhythmogenic Cardiomyopathy

Criteria for diagnosis of arrhythmogenic cardiomyopathy (ACM) were first proposed in 1994 and revised in 2010 by a Task Force. Although the Task Force criteria demonstrated a good accuracy for diagnosis of the original right ventricular phenotype (arrhythmogenic right ventricular cardiomyopathy), they lacked sensitivity for identification of the expanding phenotypic spectrum of ACM, which includes left‐sided variants and did not incorporate late‐gadolinium enhancement findings by cardiac magnetic resonance. The 2020 International criteria (“Padua criteria”) have been developed by International experts with the aim to improve the diagnosis of ACM by providing new criteria for the diagnosis of left ventricular phenotypic features. The key upgrade was the incorporation of tissue characterization findings by cardiac magnetic resonance for noninvasive detection of late‐gadolinium enhancement/myocardial fibrosis that are determinants for characterization of arrhythmogenic biventricular and left ventricular cardiomyopathy. The 2020 International criteria are heavily dependent on cardiac magnetic resonance, which has become mandatory to characterize the ACM phenotype and to exclude other diagnoses. New criteria regarding left ventricular depolarization and repolarization ECG abnormalities and ventricular arrhythmias of left ventricular origin were also provided. This article reviews the evolving approach to diagnosis of ACM, going back to the 1994 and 2010 International Task Force criteria and then grapple with the modern 2020 International criteria.

Pitfalls in arrhythmogenic left ventricular cardiomyopathy (ALVC). A review of the literature with considerations on a single case of sudden death in a juvenile athlete

Sudden cardiac death (SCD) in young athletes represents a challenging issue in forensic practice. The pathologist is frequently asked to establish the cause of death basing upon anatomical findings and to evaluate the role of the physician in preparticipation evaluation (PPE) and eligibility decision. Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a leading cause of SCD during sport activity. However, in the last few years, forms with predominant or even isolated involvement of the left ventricle (LV) have progressively been correlated with a high risk of SCD. We present a case of SCD in an apparently healthy 19-year-old semi-professional football player. Annual PPEs performed in accordance with international and Italian recommendations, were unremarkable. At autopsy, a 1-cm area of subepicardial fibro-fatty replacement was observed at the postero-lateral wall of the LV. The finding was diagnostic of arrhythmogenic left ventricular cardiomyopathy (ALVC). A review of this rare pathology has been performed under a forensic perspective, focusing on the evaluation of the medico-legal responsibility of the physician in the PPE and on the morphological aspects of the disease. Current diagnostic criteria and recommendations result to be focused on the right ventricular pattern, with a risk of misdiagnosis for isolated LV forms. Furthermore, few detailed autopsies cases concerning ALVC have been published. There is a need, therefore, to study this rare disease with a careful and revised approach.

Cardiac Structure and Function in Elite Female and Male Soccer Players

Importance

Population-specific normative data are essential for the evaluation of competitive athletes. At present, there are limited data defining normal electrocardiographic (ECG) and echocardiographic values among elite US soccer players.

Objective

To describe ECG and echocardiographic findings in healthy elite US soccer players.

Design, Setting, and Participants

This cross-sectional study analyzed Fédération Internationale de Football Association-mandated screening sessions performed at US Soccer National Team training locations from January 2015 to December 2019. US women's and men's national team soccer players undergoing mandated cardiovascular screening were included.

Main Outcomes and Measures

Normal training-related and abnormal ECG findings were reported using the International Recommendations for Electrocardiographic Interpretation in Athletes. Echocardiographic measurements of structural and functional parameters relevant to cardiovascular remodeling were assessed relative to American Society of Echocardiography guideline-defined normal ranges.

Results

A total of 238 athletes (122 [51%] female; mean [SD] age, 20 [4] years; age range, 15-40 years) were included. Male athletes demonstrated a higher prevalence of normal training-related ECG findings, while female athletes were more likely to have abnormal ECG patterns (14 [11%] vs 0 in male cohort), largely accounted for by abnormal T-wave inversions. Echocardiography revealed no pathologic findings meeting criteria for sport restriction, but athletes frequently exceeded normal ranges for structural cardiac parameters responsive to exercise-induced remodeling including body surface area-indexed left ventricular (LV) mass (58 of 113 female athletes [51%] and 67 of 114 male athletes [59%]), indexed LV volume (89 of 115 female athletes [77%] and 76 of 111 male athletes [68%]), and LV wall thickness (37 of 122 female athletes [30%] and 47 of 116 male athletes [41%]). Age-stratified analysis revealed age-dependent increases in LV wall thickness, mass, and volumes among female athletes and LV wall thickness and mass among male athletes.

Conclusions and Relevance

These data represent the first set of comprehensive normative values for elite US soccer players and one of the largest sport-specific echocardiographic remodeling studies in female athletes. Abnormal ECG findings were more common in female athletes, while both female and male athletes frequently exceeded clinical normality cut points for remodeling-associated echocardiographic parameters.

Electrocardiographic pattern of apparently healthy African adolescent athletes in Nigeria

Background

Strategies to prevent sudden cardiac death (SCD) among young athletes have become topical worldwide and unrecognized cardiac pathology has been identified as a leading cause. Black ethnicity has been reported as an independent predictor of abnormal electrocardiography (ECG) findings among athletes and the frequency and significance of training-related ECG findings versus findings suggestive of an underlying pathology in the young African athletes is crucial.

Methods

This cross sectional study aimed to determine the prevalence and distribution of ECG patterns in young athletes and controls. A total of 360 participants (180 athletes and 180 controls) were recruited from six secondary schools in Lagos, Nigeria between November 2014 and July 2015. Evaluation included interviewer-administered questionnaires for relevant history, physical examination and resting 12 - lead ECG for each participant.

Results

Abnormal ECG patterns were found in 48.3% of athletes and 35.6% of controls. Training-related ECG findings occurred in 33.3% of athletes and 18.3% of controls. Athletes and controls had 7.7% prevalence of training un-related ECG patterns respectively. Left ventricular hypertrophy was the most common ECG finding among the athletes and male athletes had a higher prevalence of ECG abnormalities compared to females.

Conclusion

Adolescent athletes in Nigeria have a high prevalence of training-related ECG patterns and athletes and non-athletes alike have similar proportions of ECG findings suggestive of underlying structural heart disease. Cardiovascular evaluation including ECG should be performed for young athletes prior to competition at any level and should also be considered as part of pre-school entry assessment for all children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02557-8.

Electrocardiographic features of arrhythmogenic right ventricular cardiomyopathy in school-aged children

It can be difficult to distinguish children with early-stage arrhythmogenic right ventricular cardiomyopathy (ARVC) from those with benign premature ventricular contraction (PVC). We retrospectively evaluated six school-aged children with ARVC and compared with those of 20 with benign PVC. The median age at initial presentation was 11.4 and 10.2 years in ARVC and benign PVC, respectively. None of the ARVC patients fulfilled the diagnostic criteria of ARVC at initial presentation. At ARVC diagnosis, the treadmill exercise test and Holter monitoring showed provoked PVC during exercise and pleomorphic PVC in all ARVC cases, respectively. During the observation period, terminal activation duration (TAD) was prolonged in all ARVC patients. In addition, ΔTAD (5.5 [3-10] ms) were significantly longer than those with benign PVC (p < 0.001). A new notched S-wave in V1 appeared in four (67%) ARVC patients, who had myocardial abnormalities in the right ventricle, and in zero benign PVC. Our electrocardiographic findings, such as provoked PVC during exercise, pleomorphic PVC, prolonged TAD, and a new notched S-wave in V1 could contribute to the early detection of ARVC in school-aged children.

Arrhythmogenic Right Ventricular Cardiomyopathy in Pediatric Patients: An Important but Underrecognized Clinical Entity

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy characterized by fibrofatty infiltration of predominantly the right ventricular (RV) myocardium. Affected patients typically present as young adults with hemodynamically stable ventricular tachycardia, although pediatric cases are increasingly recognized. These young subjects often have a more severe phenotype with a high risk of sudden cardiac death (SCD) and progression toward heart failure. Diagnosis of ARVC is made by combining multiple sources of information as prescribed by the consensus-based Task Force Criteria. The description of Naxos disease, a fully penetrant autosomal recessive disorder that is associated with ARVC and a cutaneous phenotype of palmoplantar keratoderma and wooly hair facilitated the identification of the genetic cause of ARVC. At present, approximately 60% of patients are found to carry a pathogenic variant in one of five genes associated with the cardiac desmosome. The incomplete penetrance and variable expressivity of these variants however implies an important role for environmental factors, of which participation in endurance exercise is a strong risk factor. Since there currently is no definite cure for ARVC, disease management is directed toward symptom reduction, delay of disease progression, and prevention of SCD. This clinically focused review describes the spectrum of ARVC among children and adolescents, the genetic architecture underlying this disease, the cardio-cutaneous syndromes that led to its identification, and current diagnostic and therapeutic strategies in pediatric ARVC subjects.

The determinants of positivisation of anterior T-wave inversion in children

BACKGROUND

Anterior T-wave inversion (aTWI) can be a common electrical sign in cardiomyopathies but also a benign feature regressing with age in healthy children. Unfortunately, little is known about the age of positivisation of aTWI and its determinants in children and longitudinal data are not available. The aim of this longitudinal study was to identify the age and determinants of positivisation of aTWI in healthy children.

METHODS

ATWI was observed in 331 healthy children. They were evaluated yearly until positivisation for a maximum period of 4 years. Positivisation of aTWI was observed in 312 children (94%). The weight, height/length and their respective percentiles at birth and at the time of positivisation of aTWI and weeks of gestation at birth were collected.

RESULTS

Positivisation of aTWI occurred at a mean age of 13.0±2.0 years. When aTWI became positive, the majority of children had a height between 51° and 75° or over the 75° percentile. At the multivariate logistic regression analysis height, weight, percentiles of height and weight at the time of positivisation were identified as the strongest independent predictors of the positivisation of aTWI. No correlation was found for prematurity and anthropometrics characteristics at birth.

CONCLUSIONS

ATWI is a common feature of pediatric ECG, usually regressing with age. Height, weight, percentiles of height and weight at the time of positivisation were identified as determinants of TWI positivisation. These simple anthropometric characteristics should be used in addition to chronological age in order to interpret aTWI in children.

Electrocardiographic interpretation in athletes

Participation in regular exercise of moderate intensity is associated with a plethora of systemic benefits, including a reduction in risk factors for coronary atherosclerosis; however, intensive exercise may paradoxically culminate in sudden cardiac arrest among individuals harboring arrhythmogenic substrates. The precise mechanism for arrhythmogenesis is likely multifactorial, however, surges in catecholamines, electrolyte shifts, acid-base disturbances, increased core temperature and demand myocardial ischemia are potential contributors. Although most deaths occur in middle aged and older males with atherosclerotic coronary artery disease, a significant proportion also affect young athletes with inherited or congenital cardiac abnormalities. The impact of such catastrophes on society, particularly when a young high-profile athlete is affected could be considered a justified reason for identifying individuals who may be at risk. Given the rarity of deaths in young athletes, only the simplest screening test, such as the 12-lead electrocardiography (ECG) may be considered to be cost effective. The ECG is effective for detecting serious electrical diseases in young athletes such as congenital electrical accessory pathways and ion channel diseases but can also identify athletes with potential life-threatening structural diseases such as hypertrophic and arrhythmogenic cardiomyopathy. One of the concerns about ECG screening is that regular intensive exercise results in several physiological alterations in cardiac structure and function that are reflected on the athlete's ECG. Sinus bradycardia, first-degree atrioventricular block, incomplete right bundle branch block, minor J-point elevation and large QRS voltages are common. Conversely, some repolarization anomalies affecting the ST segment, T waves and QT interval may overlap with patterns observed in patients with serious cardiac diseases. The situation is complicated further because age, sex and ethnicity of the athletes also influence the ECG and there is a risk that erroneous interpretation could have serious consequences. This review will describe the normal electrical patterns of the "athlete's heart" and provide insights into differentiation physiological electrical patterns from those observed in serious cardiac disease.

Impact of the T-wave characteristics on distinguishing arrhythmogenic right ventricular cardiomyopathy from healthy children

BACKGROUND

T-wave inversion (TWI) is not considered useful for diagnosing pediatric arrhythmogenic right ventricular cardiomyopathy (ARVC), because right precordial TWI in ARVC resembles a normal juvenile pattern.

OBJECTIVES

The aims of this study were to clarify the electrocardiographic (ECG) characteristics of pediatric ARVC to distinguish those patients from healthy children.

METHODS

Between 1979 and 2017, 11 ARVC patients under 18 years old were registered and compared with school screening ECGs from 48,401 healthy children.

RESULTS

The mean age at the first arrhythmic event or diagnosis was 13.3 ± 4.7 years. Nine patients were asymptomatic initially and were found by ECG screening, but 6 developed severe symptoms during the follow-up. Healthy children had a normal juvenile pattern, while ARVC children, especially symptomatic patients, had a significant tendency to have inferior and anterior TWI. The phenomenon of T-wave discontinuity (TWD) in which the TWI became deeper from V1 to V3 and suddenly turned positive in V5 was significantly more frequent in ARVC (60%) than healthy children (0.55%). Anterior TWI and TWD were also significantly more frequent in those who developed severe symptoms. The sensitivity and specificity of TWD were 60% (95% CI, 31-83%), and 99% (95% CI, 99-99%) to distinguish ARVC from healthy children, as well as 100% (95% CI, 71-100%) and 80% (95% CI, 51-80%), respectively, to predict severe symptoms in the future.

CONCLUSIONS

The ECG is useful to distinguish ARVC children, even in the early phase. Anterior TWI and TWD could detect ARVC children and to predict the possible serious conditions.

Criteria for interpretation of the athlete's ECG: A critical appraisal

The electrocardiogram (ECG) is cheap and widely available but its use as a screening tool for early identification of athletes with a cardiac disease at risk of sudden cardiac death is controversial because of presumed low specificity. In the last decade, several efforts have been made to improve the distinction between physiological and pathological ECG findings in the athlete, leading to continuous evolution of the interpretation criteria. The most recent 2017 International criteria grouped ECG changes into three categories: normal, borderline, and abnormal. Borderline findings warrant further investigations only when two or more are present while abnormal changes should always be considered as the sign of a possible underlying disease. This review encompasses the evolution of the athlete's ECG interpretation criteria and highlights areas of uncertainty that will need to be addressed by further studies.

The adolescent athlete's heart; A miniature adult or grown-up child?

The systematic development of early age talent in sports academies has led to the professionalization of pediatric sport and the sports physician need to be aware of pediatric cardiological problems. Research into the medical cardiac care and assessment of the pediatric athlete are accumulating, but specific pediatric international guidelines are not available yet and reference data for ECG and echocardiography are incomplete, in particular for the age group <12 years of age. This article is an introduction to the physiological and diagnostics specifics of the pediatric athlete. The focus lies in the differences in presentation and diagnosis between pediatric and adult athletes for the most common pathologies. Reference data for electrical and structural adaptations to intensive exercise are sparse particularly in athletes aged below 12 years old. Training related changes include decrease of resting heart rate, increase of cardiac output, ventricular cavity size, and wall thickness. Cardiac hypertrophy is less pronounced in pediatric athletes, as HR mediated cardiac output increase to endurance exercise is the dominant mechanism in peripubertal children. As in adults, the most pronounced cardiovascular adaptations appear in classical endurance sports like rowing, triathlon, and swimming, but the specifics of pediatric ECG and echocardiographic changes need to be considered.

Interpretation of T-wave inversion in physiological and pathological conditions: Current state and future perspectives

The presence of T‐wave inversion (TWI) at 12‐lead electrocardiogram (ECG) in competitive athletes is one of the major diagnostic challenges for sports physicians and consulting cardiologists. Indeed, while the presence of TWI may be associated with some benign conditions and it may be occasionally seen in healthy athletes presenting signs of cardiac remodeling, it may also represent an early sign of an underlying, concealed structural heart disease or life‐threatening arrhythmogenic cardiomyopathies, which may be responsible for exercise‐related sudden cardiac death (SCD). The interpretation of TWI in athletes is complex and the inherent implications for the clinical practice represent a conundrum for physicians. Accordingly, the detection of TWI should be viewed as a potential red flag on the ECG of young and apparently healthy athletes and warrants further investigations because it may represent the initial expression of cardiomyopathies that may not be evident until many years later and that may ultimately be associated with adverse outcomes. The aim of this review is, therefore, to report an update of the literature on TWI in athletes, with a specific focus on the interpretation and management.

Left ventricular hypertrophy in athletes: How to differentiate between hypertensive heart disease and athlete’s heart

Athlete’s heart is typically accompanied by a remodelling of the cardiac chambers induced by exercise. However, although competitive athletes are commonly considered healthy, they can be affected by cardiac disorders characterised by an increase in left ventricular mass and wall thickness, such as hypertension. Unfortunately, training-induced increase in left ventricular mass, wall thickness, and atrial and ventricular dilatation observed in competitive athletes may mimic the pathological remodelling of pathological hypertrophy. As a consequence, distinguishing between athlete’s heart and hypertension can sometimes be challenging. The present review aimed to focus on the differential diagnosis between hypertensive heart disease and athlete’s heart, providing clinical information useful to distinguish between physiological and pathological remodelling.

Relationship Between Electrocardiographic Findings and Cardiac Magnetic Resonance Phenotypes in Arrhythmogenic Cardiomyopathy

Background

The new designation of arrhythmogenic cardiomyopathy defines a broader spectrum of disease phenotypes, which include right dominant, biventricular, and left dominant variants. We evaluated the relationship between electrocardiographic findings and contrast‐enhanced cardiac magnetic resonance phenotypes in arrhythmogenic cardiomyopathy.

Methods and Results

We studied a consecutive cohort of patients with a definite diagnosis of arrhythmogenic cardiomyopathy, according to 2010 International Task Force criteria, who underwent electrocardiography and contrast‐enhanced cardiac magnetic resonance. Both depolarization and repolarization electrocardiographic abnormalities were correlated with the severity of dilatation/dysfunction, either global or regional, of both ventricles and the presence and regional distribution of late gadolinium enhancement. The study population included 79 patients (60% men). There was a statistically significant relationship between the presence and extent of T‐wave inversion across a 12‐lead ECG and increasing values of median right ventricular (RV) end‐diastolic volume (P<0.001) and decreasing values of RV ejection fraction (P<0.001). The extent of T‐wave inversion to lateral leads predicted a more severe RV dilatation rather than a left ventricular involvement because of the leftward displacement of the dilated RV, as evidenced by contrast‐enhanced cardiac magnetic resonance. A terminal activation delay of >55 ms in the right precordial leads (V1‐V3) was associated with higher RV volume (P=0.014) and lower RV ejection fraction (P=0.053). Low QRS voltages in limb leads predicted the presence (P=0.004) and amount (P<0.001) of left ventricular late gadolinium enhancement.

Conclusions

The study results indicated that electrocardiographic abnormalities predict the arrhythmogenic cardiomyopathy phenotype in terms of severity of RV disease and left ventricular involvement, which are among the most important determinants of the disease outcome.

Abnormal ECG Findings in Athletes: Clinical Evaluation and Considerations

PURPOSE OF REVIEW

Pre-participation cardiovascular evaluation with electrocardiography is normal practice for most sporting bodies. Awareness about sudden cardiac death in athletes and recognizing how screening can help identify vulnerable athletes have empowered different sporting disciplines to invest in the wellbeing of their athletes.

RECENT FINDINGS

Discerning physiological electrical alterations due to athletic training from those representing cardiac pathology may be challenging. The mode of investigation of affected athletes is dependent on the electrical anomaly and the disease(s) in question. This review will highlight specific pathological ECG patterns that warrant assessment and surveillance, together with an in-depth review of the recommended algorithm for evaluation.

International recommendations for electrocardiographic interpretation in athletes

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

[ECG in sportsmen: Distinguishing the normal from the pathological]

An ECG is recommended by the French Society of Cardiology in the screening of a competitive athlete. An intense and prolonged physical activity (>4 hours of intense sport/week) can lead to a physiological electric remodeling. In addition to physical activity (type, intensity, duration), the ECG should be interpreted according to the athlete's ethnicity and age. It is necessary to know the physiological modifications related to sport practice to avoid either false reassurances or the realization of unjustified additional examinations because of a wrong interpretation. The latest athlete ECG classification published in 2017 can be used to identify in which athlete additional tests are recommended (figure 1).

Normal and abnormal QT interval duration and its changes in preadolescents and adolescents practicing sport

Aims

Twelve-lead electrocardiogram (ECG) is an established tool in the evaluation of athletes, providing information about life-threatening cardiovascular diseases, such as long QT syndrome. However, the interpretation of ECG is sometimes challenging in children, particularly for the repolarization phase. The aim of this prospective, longitudinal study was to determinate the distribution of QT interval in children practicing sport and to evaluate changes in QT duration overtime.

Methods and results

A population of 1473 preadolescents practising sport (12.0 ± 1.8 years, 7–15 years) was analysed. Each athlete was evaluated at baseline, mid-term, and end of the study (mean follow-up: 3 ± 1 years). QT interval was corrected with Bazett (B) and Fridericia (F) formulae. At baseline QT interval corrected with the Bazett formula (QTcB) was 412 ± 25 ms and QT interval corrected with the Fridericia formula (QTcF) 387 ± 21 ms, with no changes during follow-up. Ten children (0.68%) had an abnormal QTc. In those with QTcB and QTcF ≥480 ms, QTc duration persisted abnormal during the follow-up and they were disqualified. Conversely, children with 460 ms < (QTcB) <480 ms had a normal QTc interval at the end of the study. These children had also a normal QTcF. Mean difference in the calculation of QT between the two formulae was 25 ± 11 ms (P < 0.0001). For resting heart rate (HR) ≥82 b.p.m., QTcF was independent from HR contrary to QTcB.

Conclusion

Normal QTc interval does not change over time in preadolescents. A minority of them has a QTc ≥480 ms; in these subjects, QTc interval remains prolonged. The use of Bazett and Fridericia correction formulae is not interchangeable and the Fridericia correction should be preferred in preadolescents with a resting HR ≥82 b.p.m.

Accuracy of the 2017 international recommendations for clinicians who interpret adolescent athletes’ ECGs: a cohort study of 11 168 British white and black soccer players

Aim

To investigate the accuracy of the recently published international recommendations for ECG interpretation in young athletes in a large cohort of white and black adolescent soccer players.

Methods

11 168 soccer players (mean age 16.4±1.2 years) were evaluated with a health questionnaire, ECG and echocardiogram; 10 581 (95%) of the players were male and 10 163 (91%) were white. ECGs were retrospectively analysed according to (1) the 2010 European Society of Cardiology (ESC) recommendations, (2) Seattle criteria, (3) refined criteria and (4) the international recommendations for ECG interpretation in young athletes.

Results

The ESC recommendations resulted in a higher number of abnormal ECGs compared with the Seattle, refined and international criteria (13.2%, 4.3%, 2.9% and 1.8%, respectively). All four criteria were associated with a higher prevalence of abnormal ECGs in black athletes compared with white athletes (ESC: 16.2% vs 12.9%; Seattle: 5.9% vs 4.2%; refined: 3.8% vs 2.8%; international 3.6% vs 1.6%; p<0.001 each). Compared with ESC recommendations, the Seattle, refined and international criteria identified a lower number of abnormal ECGs—by 67%, 78% and 86%, respectively. All four criteria identified 36 (86%) of 42 athletes with serious cardiac pathology. Compared with ESC recommendations, the Seattle criteria improved specificity from 87% to 96% in white athletes and 84% to 94% in black athletes. The international recommendations demonstrated the highest specificity for white (99%) and black (97%) athletes and a sensitivity of 86%.

Conclusions

The 2017 international recommendations for ECG interpretation in young athletes can be applied to adolescent athletes to detect serious cardiac disease. These recommendations perform more effectively than previous ECG criteria in both white and black adolescent soccer players.

Electrocardiographic and echocardiographic evaluation of a large cohort of peri-pubertal soccer players during pre-participation screening

BACKGROUND

The early diagnosis of cardiac abnormalities in young athletes may be helpful not only to identify subjects potentially at risk of sudden cardiac death but also to prevent stress-related cardiac dysfunction and cardiovascular events during the life of these subjects. The aim of our study was to investigate the prevalence of cardiac abnormalities in a population of young male soccer players undergoing pre-participation screening through electrocardiogram and trans-thoracic echocardiography.

METHODS

All consecutive male football players undergoing pre-participation screening comprehensive of medical history, physical examination, 12-lead electrocardiogram and trans-thoracic echocardiography at the FMSI Sport Medicine Institute in Rome between January 2008-March 2009 were enrolled in the study.

RESULTS

Overall, 2261 consecutive young athletes aged 12.4 ± 2.6 years were evaluated. Training-unrelated electrocardiogram abnormalities were observed in 65 (2.9%) athletes. Abnormal trans-thoracic echocardiography was observed in 102 athletes (4.5%), including two cases of hypertrophic cardiomyopathy, eight of mild left ventricular hypertrophy, six of mild left ventricular dilation and 17 of bicuspid aortic valve. An abnormal electrocardiogram was associated with anomalous trans-thoracic echocardiography in 11/65 (16.9%) cases. All athletes requiring sport disqualification were identified by electrocardiogram. Notably, among 2216 athletes with a normal electrocardiogram, 91 had abnormal trans-thoracic echocardiography, including six cases of left ventricular dilation and six of ventricular hypertrophy.

CONCLUSIONS

In a wide population of peri-pubertal male athletes, evaluation of the electrocardiogram identified all cardiac diseases requiring sport disqualification. Trans-thoracic echocardiography alone allowed the identification of cardiac abnormalities potentially leading to cardiomyopathies or major cardiovascular events over time.

Interpreting the Athlete's ECG: Current State and Future Perspectives

Sudden cardiac death (SCD) is the leading cause of death in athletes. A large proportion of these deaths are associated with undiagnosed cardiovascular disease. Screening for high-risk individuals enables early detection of pathology, as well as permitting lifestyle modification or therapeutic intervention.ECG changes in athletes occur as a result of electrical and structural adaptations secondary to repeated bouts of exercise. Such changes are common and may overlap with patterns suggestive of underlying cardiovascular disease. Correct interpretation is therefore essential, in order to differentiate physiology from pathology. Erroneous interpretation may result in false reassurance or expensive investigations for further evaluation and unnecessary disqualification from competitive sports.Interpretation of the athlete's ECG has evolved over the past 12 years, beginning with the 2005 European Society of Cardiology (ESC) consensus, progressing to the ESC recommendations (2010), Seattle Criteria (2013) and the 'refined' criteria (2014). This evolution culminated in the recently published international recommendations for ECG interpretation in athletes (2017), which has led to a significant reduction in false positives and screening-associated costs. This review aims to describe the evolution of the current knowledge on ECG interpretation as well as future directions.

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?

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%.

Common presentation of rare diseases: Arrhythmogenic right ventricular cardiomyopathy and its mimics

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is the most common phenotype described within the spectrum of arrhythmogenic cardiomyopathies. It usually presents in early adolescence with severe ventricular arrhythmias along with cardiac structural and functional alterations mainly of the right ventricular myocardium. Though the estimated prevalence of ARVC in the general population is only 1:5000, it represents one of the most common causes of juvenile sudden death. However, detection of early RV dysfunction in ARVC may be challenging requiring high clinical suspicion and an algorithmic approach. A thorough family history of juvenile sudden death, ventricular arrhythmias and ICD implants should always be sought. Diagnosis usually requires electrocardiographic interpretation as well as cardiac imaging. In this article, the key diagnostic steps in the assessment of ARVC and diagnostic red flags that aid its differential diagnosis are discussed.

Reference values of left heart echocardiographic dimensions and mass in male peri-pubertal athletes

Background

Several articles have proposed reference values in healthy paediatric subjects, but none of them has evaluated a large population of healthy trained adolescents.

Design

The study purpose was to establish normal echocardiographic measurements of left heart (aortic root, left atrium and left ventricular dimensions and mass) in relation to age, weight, height, body mass index, body surface area and training hours in this specific population.

Methods

We retrospectively evaluated 2151 consecutive, healthy, peri-pubertal athletes (100% male, mean age 12.4 ± 1.4 years, range 8–18) referred to a single centre for pre-participation screening. All participants were young soccer athletes who trained for a mean of 7.2 ± 1.1 h per week.

Results

Left ventricular internal diameters, wall thickness, left ventricular mass, aortic root and left atrium diameters were significantly correlated to age, body surface area, height and weight ( p < 0.01). Age, height, weight and body surface area were found associated with chamber size, while body mass index and training hours were not. Inclusion of both age and body size parameters in the statistical models resulted in improved overall explained variance for diameters and left ventricular mass.

Conclusion

Equations, mean values and percentile charts for the different age groups may be useful as reference data in efficiently assessing left ventricular parameters in young athletes.