Interpreting the Athlete's EKG: are all repolarization anomalies created equal?

Guide to the Female Student Athlete ECG: A Comprehensive Study of 3466 Young, Racially Diverse Athletes

OBJECTIVES

The 12-lead electrocardiogram (ECG) is used in the preparticipation screening examination for athletes. Despite known differences in ECG findings by sex, only QTc prolongation is given a sex-specific threshold. We hypothesize that our large dataset-with diversity in age, race, and sport participation-can be utilized to improve ECG screening in female student athletes.

METHODS

Computerized 12-lead ECGs were recorded and analyzed in female athletes who underwent preparticipation screening examination between June 2010 and September 2021. The quantitative, empirical 2017 international criteria for electrocardiographic interpretation were compared with either the 99th percentile in our cohort or the percentile that corresponded to the known disease prevalence.

RESULTS

Of 3466 female athletes with ECGs as part of preparticipation screening examination, the 2017 international criteria classified 2.1% of athletes with at least one ECG abnormality requiring cardiological evaluation. Rates were similar across age, race/ethnicity, and sporting discipline. Using ranges based on our population, 2.7% of athletes would require additional workup. Surprisingly, ST depression up to 0.03 mV was a normal finding in this cohort. If RS voltage extremes were considered findings requiring follow-up, an additional 9.6% of the athlete population would be flagged using current definitions. This number decreases to 2.7% if using the 99th percentile in this cohort.

CONCLUSION

These results highlight a difference in the reported prevalence of ECG abnormalities when comparing empirically derived thresholds to statistically derived ranges. Consideration of new metrics specific to the female athlete population has the potential to further refine athlete ECG screening.

Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review

BACKGROUND

The incidence and cause of sudden cardiac death (SCD) in athletes is debated with hypertrophic cardiomyopathy often reported as the most common cause.

METHODS AND RESULTS

A database of all National Collegiate Athletic Association deaths (2003-2013) was developed. Additional information and autopsy reports were obtained when possible. Cause of death was adjudicated by an expert panel. There were 4 242 519 athlete-years (AY) and 514 total student athlete deaths. Accidents were the most common cause of death (257, 50%, 1:16 508 AY) followed by medical causes (147, 29%, 1:28 861 AY). The most common medical cause of death was SCD (79, 15%, 1:53 703 AY). Males were at higher risk than females 1:37 790 AY versus 1:121 593 AY (incidence rate ratio, 3.2; 95% confidence interval, 1.9-5.5; P<0.00001), and black athletes were at higher risk than white athletes 1:21491 AY versus 1:68 354 AY (incidence rate ratio, 3.2; 95% confidence interval, 1.9-5.2; P<0.00001). The incidence of SCD in Division 1 male basketball athletes was 1:5200 AY. The most common findings at autopsy were autopsy-negative sudden unexplained death in 16 (25%), and definitive evidence for hypertrophic cardiomyopathy was seen in 5 (8%). Media reports identified more deaths in higher divisions (87%, 61%, and 44%), whereas the percentages from the internal database did not vary (87%, 83%, and 89%). Insurance claims identified only 11% of SCDs.

CONCLUSIONS

The rate of SCD in National Collegiate Athletic Association athletes is high, with males, black athletes, and basketball players at substantially higher risk. The most common finding at autopsy is autopsy-negative sudden unexplained death. Media reports are more likely to capture high-profile deaths, and insurance claims are not a reliable method for case identification.