ECGs in Athletes
Corrado et al. have published an ESC consensus document on the screening of athletes for competitive sports. 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.
Prevalence of ECG abnormalities in competitive athletes has been studied by Pellicia et al.(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 left ventricular hypertrophy were often seen.
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%..
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 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.
Criteria for a positive ECG
|ST-segment, T-waves, and QT interval||
|Rhythm and conduction abnormalities||
Cardiac diseases and their ECG features
|Disease||QTc interval||P wave||PR interval||QRS complex||ST interval||T wave||Arrhythmias|
|HCM||Normal||(left atrial enlargement)||Normal||Increased voltages in mid-left precordial leads; abnormal Q waves in inferior and / or lateral leads; (LAD, LBBB); (delta wave)||Down-sloping (up-sloping)||Inverted in mid-left precordial leads; (giant and negative in the apical variant)||(Atrial ﬁbrillation); (PVB); (VT)|
|Arrhythmogenic right ventricular cardiomyopathy / dysplasia||Normal||Normal||Normal||Prolonged > 110 ms in right precordial leads; epsilon wave in right precordial leads; reduced voltages <= 0.5 mV in frontal leads; (RBBB)||(Up-sloping in right precordial leads)||Inverted in right precordial leads||PVB with a LBBB pattern; (VT with a LBBB pattern)|
|Dilated cardiomyopathy||Normal||(Left atrial enlargement)||(Prolonged >= 0.21s)||LBBB||Down-sloping (up-sloping)||Inverted in inferior and / or lateral leads||PVB; (VT)|
|Long QT syndrome||Prolongedc
||Normal||Normal||Normal||Normal||Biﬁd or biphasic in all leads||(PVB); (torsade de pointes)|
|Brugada Syndrome||Normal||Prolonged >= 0.21s||S1S2S3 pattern; (RBBB/LAD)||Up-sloping coved-type in right precordial leads||Inverted in right precordial leads||(Polymorphic VT); (atrial fibrillation) (sinus tachycardia)|
|Lenègre disease||Normal||Normal||Prolonged >= 0.21s||RBBB; RBBB/LAD; LBBB||Normal||Secondary changes||(2nd or 3rd degree AV block)|
|Short QT Syndrome||Shortened < 300 ms||Normal||Normal||Normal||Normal||Normal||Atrial ﬁbrillation (polymorphic VT)|
|Pre-excitation syndrome (WPW)||Normal||Normal||Shortened < 0.12s||Delta wave||Secondary changes||Secondary changes||Supraventricular tachycardia; (atrial fibrillation)|
|Coronary artery diseasesa||(Prolonged)||Normal||Normal||(Abnormal Q waves)b||(Down-or up-sloping)||Inverted in >= 2 leads||PVB; (VT);|
Prevalence of ECG abnormalities in athletes
|ECG abnormalities||Athletes, n (%)|
|Negative T-waves in precordial/standard leads||751 (2.3)|
|Increased R/S wave voltages (suggestive of LVH)||247 (0.8)|
|Left anterior fascicular block||162 (0.5)|
|Pre-excitation pattern||42 (0.1)|
|Prolonged corrected QT interval||1 (0.003)|
|Others (incomplete RBBB, prolonged PR interval, early repolarization pattern)||2280 (7.0)|
Classification of abnormalities of the athlete’s electrocardiogram
|Group 1: common and training-related ECG changes||Group 2: uncommon and training-unrelated ECG changes|
RBBB, right bundle branch block; LBBB, left bundle branch block.
- 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