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Corrado et al. have published an ESC consensus document on the screening of athletes for competitive sports.<cite>Corrado</cite> Besides a good medical history and examination, a 12 lead ECG is also part of the screening. They have set up special ECG criteria for participants in competitive sports (table 1). If one of the described findings are present on the ECG, the ECG is considered 'positive' and further evaluation is mandatory which can include echocardiography, 24-h ambulatory Holter monitoring, and exercise testing. ECG Features of cardiac diseases detectable at pre-participation screening in young competitive athletes are shown in table 2.
Corrado et al. have published an ESC consensus document on the screening of athletes for competitive sports.<cite>Corrado</cite> Besides a good medical history and examination, a 12 lead ECG is also part of the screening. They have set up special ECG criteria for participants in competitive sports (table 1). If one of the described findings are present on the ECG, the ECG is considered 'positive' and further evaluation is mandatory which can include echocardiography, 24-h ambulatory Holter monitoring, and exercise testing. ECG Features of cardiac diseases detectable at pre-participation screening in young competitive athletes are shown in table 2.


{| class="wikitable" font-size="75%"
Prevalence of ECG abnormalities in competitive athletes has been studied by Pellicia et al.<cite>Pellicia</cite>(see table below). ECG abnormalities in their study increased with age and level of exercise. In young amateur athletes they found ECG abnormalities in about 7%, a number that rose to 40% in "adult elite athletes". Especially [[RBBB]] and [[lvh|left ventricular hypertrophy]] were often seen.
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A recent study investigated ECG and echocardiographies in male athletes of African / Afro-Caribbean origin and found frequent T wave inversions in leads V1-V4. Significant ST elevation was present in 63.2% and LVH in 23.2%.<cite>Papadakis</cite>.
 
Recently fierce debate has been going on about whether an ECG should be part of the screening of apparently healthy young sporters. In Italy this screening is compulsory by law and this country is a strong advocate of the use of an ECG as part of this screening. However, others<cite>Chaitman</cite> have stated that costs are too high for the yield (expressed in dollars per prevented sudden cardiac death) and an ECG is not included in the screening protocol of the American Heart Association.<cite>Maron</cite><cite>Myerburg</cite>
==Criteria for a positive ECG==
{| class="wikitable" style="font-size:90%;"
|-  
|+'''Table 1: Criteria for a positive 12-lead ECG'''
|+'''Table 1: Criteria for a positive 12-lead ECG'''
|-
|-
!P wave
!P wave
|-
|
|
<ul>
<ul>
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|-
|-
!QRS complex
!QRS complex
|-
|
|
<ul>
<ul>
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|-
|-
!ST-segment, T-waves, and QT interval
!ST-segment, T-waves, and QT interval
|-
|
|
<ul>
<ul>
<li>ST-segment depression or T-wave flattening or inversion in two or more leads;</li>
<li>ST-segment depression or T-wave flattening or inversion in two or more leads;</li>
<li>prolongation of heart rate corrected QT interval (QTc) > 0.44 s in males and > 0.46 s in females.</li>
<li>prolongation of heart rate corrected QT interval (QTc) > 0.44 s in males and > 0.46 s in females.<sup>c</sup></li>
</ul>
</ul>
|-
|-
!Rhythm and conduction abnormalities
!Rhythm and conduction abnormalities
|-
|
|
<ul>
<ul>
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<li>supraventricular tachycardias, atrial flutter, or atrial fibrillation;</li>
<li>supraventricular tachycardias, atrial flutter, or atrial fibrillation;</li>
<li>short PR interval (< 0.12 s) with or without ‘delta’ wave;</li>
<li>short PR interval (< 0.12 s) with or without ‘delta’ wave;</li>
<li>sinus bradycardia with resting heart rate ≤ 40 beats/mina;<sup>a</sup></li>
<li>sinus bradycardia with resting heart rate ≤ 40 beats/min;<sup>a</sup></li>
<li>first (PR ≥ 0.21 s<sup>b</sup>), second or third degree atrioventricular block.</li>
<li>first (PR ≥ 0.21 s<sup>b</sup>), second or third degree atrioventricular block.</li>
</ul>
</ul>
|-
|-  
|<sup>a</sup>Increasing less than 100 beats/min during limited exercise test.
| colspan="2" style="text-align:left;"  font-size="80%"|
<sup>b</sup>Not shortening with hyperventilation or limited exercise test.
*<sup>a</sup>Increasing less than 100 beats/min during limited exercise test.
*<sup>b</sup>Not shortening with hyperventilation or limited exercise test.
*<sup>c</sup>A recent study suggests athletes with a QTc > 500ms should be recommended not to participate in competitive sports<cite>Moss</cite><cite>Basavarajaiah</cite>
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|-
|}
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{| class="wikitable" font-size="80%"
==Cardiac diseases and their ECG features==
|- style="text-align:center;background-color:#6EB4EB;"
{| class="wikitable" style="font-size:90%;"
|-  
|+'''Table 2: ECG Features of cardiac diseases detectable at pre-participation screening in young competitive athletes'''
|+'''Table 2: ECG Features of cardiac diseases detectable at pre-participation screening in young competitive athletes'''
! Disease
! Disease
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! Arrhythmias
! Arrhythmias
|-
|-
! HCM
! [[Clinical_Disorders#Hypertrophic_Obstructive_Cardiomyopathy|HCM]]
| Normal
| Normal
| (left atrial enlargement)
| (left atrial enlargement)
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| (Atrial fibrillation); (PVB); (VT)
| (Atrial fibrillation); (PVB); (VT)
|-
|-
! Arrhythmogenic right ventricular cardiomyopathy / dysplasia
! [[arvd|Arrhythmogenic right ventricular cardiomyopathy / dysplasia]]
| Normal
| Normal
| Normal
| Normal
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| PVB; (VT)
| PVB; (VT)
|-
|-
! Long QT syndrome
! [[lqts|Long QT syndrome]]
| Prolonged
| Prolonged<sup>c</sup>
*> 440ms in males
*> 440ms in males
*> 460ms in females
*> 460ms in females
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| (PVB); (torsade de pointes)
| (PVB); (torsade de pointes)
|-
|-
! Brugada syndrome
! [[Brugada Syndrome]]
| Normal
| Normal
|
|
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| (2nd or 3rd degree AV block)
| (2nd or 3rd degree AV block)
|-
|-
! Short QT syndrome
! [[Short QT Syndrome]]
| Shortened < 300 ms
| Shortened < 300 ms
| Normal
| Normal
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| Atrial fibrillation (polymorphic VT)
| Atrial fibrillation (polymorphic VT)
|-
|-
! Pre-excitation syndrome (WPW)
! [[WPW|Pre-excitation syndrome (WPW)]]
| Normal
| Normal
| Normal
| Normal
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*<sup>a</sup>Coronary artery diseases: either premature coronary atherosclerosis or congenital coronary anomalies.
*<sup>a</sup>Coronary artery diseases: either premature coronary atherosclerosis or congenital coronary anomalies.
*<sup>b</sup>Abnormal Q waves (table 1)
*<sup>b</sup>Abnormal Q waves (table 1)
*<sup>c</sup>A recent study suggests athletes with a QTc > 500ms should be recommended not to participate in competitive sports<cite>Moss</cite><cite>Basavarajaiah</cite>
|-
|}
==Prevalence of ECG abnormalities in athletes==
{| class="wikitable" style="font-size:90%;"
|-
|+Table 3: Prevalence of ECG abnormalities in an unselected population of 32 652 young individuals undergoing the pre-participation cardiovascular screening'''
! ECG abnormalities
! Athletes, ''n'' (%)
|-
! Negative T-waves in precordial/standard leads
| align="left" valign="top" | 751 (2.3)
|-
! [[RBBB]]
| align="left" valign="top" | 351 (1.0)
|-
! Increased R/S wave voltages (suggestive of LVH)
| align="left" valign="top" | 247 (0.8)
|-
! [[Left anterior fascicular block]]
| align="left" valign="top" | 162 (0.5)
|-
! [[wpw|Pre-excitation pattern]]
| align="left" valign="top" | 42 (0.1)
|-
! [[LBBB]]
| align="left" valign="top" | 19 (0.1)
|-
! Prolonged corrected QT interval
| align="left" valign="top" | 1 (0.003)
|-
! Others (incomplete [[RBBB]], prolonged PR interval, early repolarization pattern)
| align="left" valign="top" | 2280 (7.0)
|-
! Total
| align="left" valign="top" | 3853 (11.8)
|-
| colspan="2" style="text-align:left;"  font-size="80%"|
*RBBB, right bundle branch block; LVH, left ventricular hypertrophy; LBBB, left bundle branch block.<cite>Pellicia</cite>
|-
|-
|}
|}




==Classification of abnormalities of the athlete’s electrocardiogram==
{| class="wikitable" style="font-size:90%;"
|-
|+Table 4: Classification of abnormalities of the athlete’s electrocardiogram<cite>Corrado2</cite>
! Group 1: common and training-related ECG changes
! Group 2: uncommon and training-unrelated ECG changes
|-
| style="vertical-align:top;" |
<ul>
<li>Sinus bradycardia</li>
<li>First-degree AV block</li>
<li>Incomplete [[RBBB]]</li>
<li>Early repolarization</li>
<li>Isolated QRS voltage criteria for left ventricular hypertrophy</li>
</ul>


|
<ul>
<li>T-wave inversion</li>
<li>ST-segment depression</li>
<li>Pathological Q-waves</li>
<li>Left atrial enlargement</li>
<li>Left-axis deviation/left anterior hemiblock</li>
<li>Right-axis deviation/left posterior hemiblock</li>
<li>Right ventricular hypertrophy</li>
<li>Ventricular pre-excitation</li>
<li>Complete [[LBBB]] or [[RBBB]]</li>
<li>Long- or short-QT interval</li>
<li>Brugada-like early repolarization</li>
</ul>
|-
| colspan="2" style="text-align:left;"  font-size="80%"|
RBBB, right bundle branch block; LBBB, left bundle branch block.
|}


==References==
==References==
<biblio>
<biblio>
#Corrado pmid=15689345
#Corrado pmid=15689345
#Pellicia pmid=17623682
#Maron pmid=17353433
#Myerburg pmid=18040041
#Chaitman pmid=18040040
#Basavarajaiah pmid=17947213
#Moss pmid=17967824
#Corrado2 pmid=19933514
#Papadakis pmid=21613263
</bilbio>
</bilbio>
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