Benefits and limitations of electrocardiographic and echocardiographic screening in top level endurance athletes

The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions

Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.

[Iliac endofibrosis in high-performance sports: an interdisciplinary diagnostic challenge]

OBJECTIVES

Iliac endofibrosis (IE) is a rare arterial disease in endurance athletes, especially cyclists and triathletes. The diagnosis is considered challenging and the latency from the onset of initial symptoms to diagnosis is often several years. Diagnostic options include determination of the ankle brachial index (ABI) after maximal exercise as a non-invasive procedure, as well as duplex sonography, CT or MRI angiography, and invasive angiography. The aim of this paper is to analyse in more detail this time lag to correct diagnosis from the first description in 1985 to the year 2021, as well as to identify the most important diagnostic tools for practice.

MATERIALS AND METHODS

Literature research according to PRISMA criteria in PubMed, Web of Science, Cochrane databases, supplemented by a search in Google Scholar up to 10/18/2021.

RESULTS

We identified a total of 133 publications that dealt thematically with IE in endurance athletes. In 42 publications (40 case reports and 2 clinical trials), the diagnosis was confirmed intraoperatively, and in 32 (32/42; 74.4%), statements were made about the duration from the onset of the first symptoms to the final diagnosis (mean 45, median 36 months). This latency was constant over the entire observation period from 1985 to 2021, with no trend toward shortening. Twenty-four papers (24/42; 56%) reported detailed results of ABI determination as well as further diagnostic testing. In all cases, the ABI value decreased to less than 0.66 (in 5 case reports, this decrease was measured at rest; in 19 case reports, it occurred after stress), whereas further diagnostic testing by duplex sonography, DSA, MRA, or CTA revealed no abnormal findings in 3 cases (3/24; 12.5%) and showed no more than minor stenosis in 14 cases (14/24; 58.3%).

CONCLUSIONS

A drop in ABI after exercise is the most reliable method to diagnose iliac endofibrosis. This non-invasive and easy-to-perform examination should be integrated into the performance diagnostics of highly ambitious endurance athletes at risk. This may ideally prevent irreversible vessel wall damage by early diagnosis as well as a reduction of the presumed high number of undetected cases.

Time domain adaptation of left ventricular diastolic intraventricular pressure in elite female ice hockey athletes

Background

Ice hockey is a high-intensity dynamic sport for which competitive athletes train for longer than 20 hours each week for several years. The cumulative time of myocardial exposure to hemodynamic stress affects cardiac remodeling. However, the intracardiac pressure distribution of the elite ice hockey athletes' heart during adaptation to long-term training remains to be explored. This study aimed to compare the diastolic intraventricular pressure difference (IVPD) of the left ventricle (LV) between healthy volunteers and ice hockey athletes with different training times.

Methods

Fifty-three female ice hockey athletes (27 elite and 26 casual) and 24 healthy controls were included. The diastolic IVPD of the LV during diastole was measured by vector flow mapping. The peak amplitude of the IVPD during isovolumic relaxation (P0), diastolic rapid filling (P1), and atrial systole (P4); the difference in the peak amplitude between adjacent phases (DiffP01, DiffP14); the time interval between the peak amplitude of adjacent phases (P0P1, P1P4); and the maximum decrease rate in diastolic IVPD were calculated. Differences between groups, as well as correlations between hemodynamic parameters and training time, were analyzed.

Results

Structural parameters of the LV were significantly higher in elite athletes than in casual players and controls. No significant difference in the peak amplitude of the IVPD during the diastolic phase was found among the three groups. The analysis of covariance with heart rate as a covariate showed that P1P4 in the elite athlete and casual player groups was significantly longer than that in the healthy control group (p < 0.001 for all). An increased P1P4 was significantly associated with an increased training year (β = 4.90, p < 0.001).

Conclusions

The diastolic cardiac hemodynamics of the LV in elite female ice hockey athletes could be characterized by a prolonged diastolic IVPD, and P1P4 prolonged with an increase in the training years, reflecting a time-domain adaptation in diastolic hemodynamics after long-term training.

The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions

Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.

A Pilot Study of the Reliability and Agreement of Heart Rate, Respiratory Rate and Short-Term Heart Rate Variability in Elite Modern Pentathlon Athletes

Research on reliability of heart rate variability (HRV) parameters in athletes has received increasing attention. The aims of this study were to examine the inter-day reliability of short-term (5 min) and ultra-short-term (1 min) heart rate (HR), respiratory rate (RespRate) and HRV parameters, agreement between short-term and ultra-short-term parameters, and association between differences in HR, RespRate and HRV parameters in elite modern pentathletes. Electrocardiographic recordings were performed in stable measurement conditions with a week interval between tests. Relative reliability was evaluated by intra-class correlation coefficients, absolute reliability was evaluated by within-subject coefficient of variation, and agreement was evaluated using Bland-Altman (BA) plot with limits of agreement and defined a priori maximum acceptable difference. Short-term HR, RespRate, log transformed (ln) root mean square of successive normal-to-normal interval differences (lnRMSSD), ln high frequency (lnHF) and SD2/SD1 HRV indices and ultra-short-term HR, RespRate and lnRMSSD presented acceptable, satisfactory inter-day reliability. Although there were no significant differences between short-term and ultra-short-term HR, RespRate and lnRMSSD, no parameter showed acceptable differences with BA plots. Differences in time-domain and non-linear HRV parameters were more correlated with differences in HR than with differences in RespRate. Inverse results were observed for frequency-domain parameters. Short-term HR, RespRate, lnRMSSD, lnHF, and SD2/SD1 and ultra-short-term HR, RespRate and lnRMSSD could be used as reliable parameters in endurance athletes. However, practitioners should interpret changes in HRV parameters with regard to concomitant differences in HR and RespRate and caution should be taken before considering 5 min and 1 min parameters as interchangeable.