EKG in athletes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

## Contents

* 1 Overview
* 2 Criteria for a positive EKG
* 3 Cardiac diseases and their EKG features
* 4 Prevalence of EKG abnormalities in athletes
* 5 References
* 6 Source
* 7 External links

## Overview

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Corrado et al. have published an ESC consensus document on the screening of athletes for competitive sports.[1] Besides a good medical history and examination, a 12 lead EKG is also part of the screening. They have set up special EKG criteria for participants in competitive sports (table 1). If one of the described findings are present on the EKG, the EKG is considered 'positive' and further evaluation is mandatory which can include echocardiography, 24-h ambulatory Holter monitoring, and exercise testing. EKG Features of cardiac diseases detectable at pre-participation screening in young competitive athletes are shown in table 2. [1] [2] [3] [4] [5] [6] [7]

Prevalence of EKG abnormalities in competitive athletes has been studied by Pellicia et al.[2](see table below). EKG abnormalities in their study increased with age and level of exercise. In young amateur athletes they found EKG abnormalities in about 7%, a number that rised to 40% in "adult elite athletes". Especially RBBB and left ventricular hypertrophy were often seen.

Recently fierce debate has been going on about whether an EKG 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 EKG as part of this screening. However, others[6] have stated that costs are too high for the yield (expressed in dollars per prevented sudden cardiac death) and an EKG is not included in the screening protocol of the American Heart Association.[3] [4]

## Criteria for a positive EKG

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Table 1: Criteria for a positive 12-lead EKG P wave  |

* left atrial enlargement: negative portion of the P wave in lead V1 ≥ 0.1 mV in depth and ≥ 0.04 s in duration
* right atrial enlargement: peaked P wave in leads II and III or V1 ≥ 0.25 mV in amplitude

|

QRS complex  |

* frontal plane axis deviation: right ≥ +120° or left –30° to –90°;
* increased voltage: amplitude of R or S wave in in a standard lead ≥2 mV, S wave in lead V1 or V2 ≥ 3 mV, or R wave in lead V5 or V6 ≥ 3 mV;
* abnormal Q waves ≥ 0.04 s in duration or ≥ 25% of the height of the ensuing R wave or QS pattern in two or more leads;
* right or left bundle branch block with QRS duration ≥ 0.12 s;
* R or R' wave in lead V1 ≥ 0.5 mV in amplitude and R/S ratio ≥ 1.

ST-segment, T-waves, and QT interval  |

* ST-segment depression or T-wave flattening or inversion in two or more leads;
* prolongation of heart rate corrected QT interval (QTc) > 0.44 s in males and > 0.46 s in females.c

Rhythm and conduction abnormalities  |

* premature ventricular beats or more severe ventricular arrhythmias;
* supraventricular tachycardias, atrial flutter, or atrial fibrillation;
* short PR interval (< 0.12 s) with or without ‘delta’ wave;
* sinus bradycardia with resting heart rate ≤ 40 beats/min;a
* first (PR ≥ 0.21 sb), second or third degree atrioventricular block.

* aIncreasing less than 100 beats/min during limited exercise test.
* bNot shortening with hyperventilation or limited exercise test.
* cA recent study suggests athletes with a QTc > 500ms should be recommended not to participate in competitive sports[5] [7]

## Cardiac diseases and their EKG features

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Table 2: EKG Features of cardiac diseases detectable at pre-participation screening in young competitive athletes 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 / Arrhythmogenic right ventricular 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

* > 440ms in males
* > 460ms in females

| 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);

* Less common or uncommon EKG ﬁndings are reported in brackets.
* QTc: QT interval corrected for heart rate by Bazett’s formula. LBBB: left bundle branch block. RBBB: right bundle branch block. LAD: left axis deviation of –30 degrees or more. PVB: either single or coupled premature ventricular beats. VT: either non-sustained or sustained ventricular tachycardia.
* aCoronary artery diseases: either premature coronary atherosclerosis or congenital coronary anomalies.
* bAbnormal Q waves (table 1)
* cA recent study suggests athletes with a QTc > 500ms should be recommended not to participate in competitive sports[5] [7]

## Prevalence of EKG abnormalities in athletes

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Table 3: Prevalence of EKG abnormalities in an unselected population of 32 652 young individuals undergoing the pre-participation cardiovascular screening EKG abnormalities  | Athletes, n (%)

|

Negative T-waves in precordial/standard leads  | 751 (2.3)
RBBB | 351 (1.0)
Increased R/S wave voltages (suggestive of LVH)  | 247 (0.8)
Left anterior fascicular block | 162 (0.5)
Pre-excitation pattern | 42 (0.1)
LBBB | 19 (0.1)
Prolonged corrected QT interval  | 1 (0.003)
Others (incomplete RBBB, prolonged PR interval, early repolarization pattern)  | 2280 (7.0)
Total  | 3853 (11.8)

* RBBB, right bundle branch block; LVH, left ventricular hypertrophy; LBBB, left bundle branch block.[2]

## References

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1. ↑ 1.0 1.1 Corrado D, Pelliccia A, Bjørnstad HH, Vanhees L, Biffi A, Borjesson M, Panhuyzen-Goedkoop N, Deligiannis A, Solberg E, Dugmore D, Mellwig KP, Assanelli D, Delise P, van-Buuren F, Anastasakis A, Heidbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E, Blomstrom-Lundqvist C, McKenna WJ, Thiene G; Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005 Mar;26(5):516-24. PMID 15689345
2. ↑ 2.0 2.1 2.2 Pelliccia A, Culasso F, Di Paolo FM, Accettura D, Cantore R, Castagna W, Ciacciarelli A, Costini G, Cuffari B, Drago E, Federici V, Gribaudo CG, Iacovelli G, Landolfi L, Menichetti G, Atzeni UO, Parisi A, Pizzi AR, Rosa M, Santelli F, Santilio F, Vagnini A, Casasco M, Di Luigi L. Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Heart J. 2007 Aug;28(16): 2006-10. PMID 17623682
3. ↑ 3.0 3.1 Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, Dimeff R, Douglas PS, Glover DW, Hutter AM Jr, Krauss MD, Maron MS, Mitten MJ, Roberts WO, Puffer JC; American Heart Association Council on Nutrition, Physical Activity, and Metabolism. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007 Mar 27;115(12):1643-455. PMID 17353433
4. ↑ 4.0 4.1 Myerburg RJ, Vetter VL. Electrocardiograms should be included in preparticipation screening of athletes. Circulation. 2007 Nov 27; 116 (22): 2616-26. PMID 18040041
5. ↑ 5.0 5.1 5.2 Moss AJ. What duration of the QTc interval should disqualify athletes from competitive sports? Eur Heart J. 2007 Dec;28 (23): 2825-6. PMID 17967824
6. ↑ 6.0 6.1 Chaitman BR. An electrocardiogram should not be included in routine preparticipation screening of young athletes. Circulation. 2007 Nov 27; 116 (22): 2610-4. PMID 18040040
7. ↑ 7.0 7.1 7.2 Basavarajaiah S, Wilson M, Whyte G, Shah A, Behr E, Sharma S. Prevalence and significance of an isolated long QT interval in elite athletes. Eur Heart J. 2007 Dec;28(23):2944-9. PMID 17947213

## Source

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* ECGpedia

## External links

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* The MD TV: Comments on Hot Topics, State of the Art Presentations in Cardiovascular Medicine, Expert Reviews on Cardiovascular Research
* Clinical Trial Results: An up to date resource of Cardiovascular Research

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Electrocardiography

Overview|

History of the EKG • EKG interpretation basics • Normal sinus rhythm

EKG Complexes|

P wave • QRS complex • ST Segment • T wave • T wave alternans • Tombstone T wave • U wave

Osborn wave • H wave • K wave • Delta wave

NSSTW changes

EKG Intervals|

PR Interval • QRS Interval • ST Interval • QT Interval

Conduction System & Bradycardia|

Cardiac pacemaker • SA node • AV node• Bundle of His • Purkinje fibers • Sinus bradycardia • First Degree AV Block • Second Degree AV Block • Complete or Third-Degree AV Block • Concealed conduction • AV Junctional Rhythms • LBBB • LAHB • LPHB • RBBB • Trifascicular block

Atrial Arrhythmias|

Sinus tachycardia • Premature Atrial Contractions (PACs) • Ectopic Atrial Rhythm • Paroxysmal Atrial Tachycardia (PAT) • Paroxysmal Atrial Tachycardia (PAT) with Block • Multifocal Atrial Tachycardia (MAT) • Atrial Flutter • Atrial Fibrillation • Wandering atrial pacemaker

Ventricular Arrhythmias|

Differential Diagnosis of Tachycardia with a Wide QRS Complex • Accelerated Idioventricular Rhythm • Ventricular Parasystole • Premature Ventricular Contractions (PVCs) • Ventricular tachycardia • Ventricular Fibrillation • Sudden cardiac death

EKG Abnormalities in Disease States|

Hypertrophy & Dilatation • Right atrial enlargement • Left atrial enlargement • Biatrial enlargement • Left Ventricular Hypertrophy • Right Ventricular Hypertrophy • Biventricular Hypertrophy •

Acute myocardial infarction • NSTEMI • STEMI • Tombstone ST elevation • Right ventricular myocardial infarction • Atrial infarction

Pre-excitation Syndromes • Wolff-Parkinson-White Syndrome • Lown Ganong Levine Syndrome • Mahaim Type Preexcitation

Cardiomyopathies • Arrhythmogenic Right Ventricular Dysplasia • Dilated Cardiomyopathy • Hypertrophic Cardiomyopathy

Drug Effects on the EKG • Adenosine • β-blockers • Digitalis • Quinidine • Procainamide • Disopyramide • Lidocaine • Tocainide and Mexiletine • Phenytoin • Encainide, Flecainide and Propafenone • Amiodarone • Bretylium • Ca Channel Blockers • Phenothiazines • Tricyclic Antidepressants • Lithium

Congenital Heart Disease • Dextrocardia • Atrial Septal Defect • Ventricular Septal Defect • Tetralogy of Fallot • Conjoined Twins or Siamese Twins • Congenital heart block

Electrolyte Disturbances • Hyperkalemia • Hypokalemia • Hypercalcemia • Hypocalcemia • Nonspecific Changes

Other Heart Diseases • Pericarditis • Myocarditis • Tamponade • Heart Transplantation • Sick Sinus Syndrome • Long QT Syndrome

Inherited Disease • Brugada Syndrome

Systemic Diseases • CNS Disease • Cardiac Tumors

Heart Transplantation • EKG Changes in patient with Heart Transplantation

Exogenous Effects • Hypothermia • Chest Trauma • Insect Bites • Electric Injuries

Technical Issues and Potential Errors in Interpretation|

Artifacts • Lead Placement Errors • The EKG in a Patient with a Pacemaker • EKG in athletes

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Cardiovascular disease (heart)

Ischaemic|

| Coronary disease|

* Coronary artery disease (CAD)
* Coronary artery aneurysm
* Spontaneous coronary artery dissection (SCAD)
* Coronary thrombosis
* Coronary vasospasm
* Myocardial bridge

|

Active ischemia|

* Angina pectoris
* Prinzmetal's angina
* Stable angina
* Acute coronary syndrome
* Myocardial infarction
* Unstable angina

Sequelae|

* hours
* Hibernating myocardium
* Myocardial stunning
* days
* Myocardial rupture
* weeks
* Aneurysm of heart / Ventricular aneurysm
* Dressler syndrome

Layers|

| Pericardium|

* Pericarditis
* Acute
* Chronic / Constrictive
* Pericardial effusion
* Cardiac tamponade
* Hemopericardium

|

Myocardium|

* Myocarditis
* Chagas disease
* Cardiomyopathy
* Dilated
* Alcoholic
* Hypertrophic
* Tachycardia-induced
* Restrictive
* Loeffler endocarditis
* Cardiac amyloidosis
* Endocardial fibroelastosis
* Arrhythmogenic right ventricular dysplasia

Endocardium /
valves|

| Endocarditis|

* infective endocarditis
* Subacute bacterial endocarditis
* non-infective endocarditis
* Libman–Sacks endocarditis
* Nonbacterial thrombotic endocarditis

|

Valves|

* mitral
* regurgitation
* prolapse
* stenosis
* aortic
* stenosis
* insufficiency
* tricuspid
* stenosis
* insufficiency
* pulmonary
* stenosis
* insufficiency

Conduction /
arrhythmia|

| Bradycardia|

* Sinus bradycardia
* Sick sinus syndrome
* Heart block: Sinoatrial
* AV
* 1°
* 2°
* 3°
* Intraventricular
* Bundle branch block
* Right
* Left
* Left anterior fascicle
* Left posterior fascicle
* Bifascicular
* Trifascicular
* Adams–Stokes syndrome

|

Tachycardia
(paroxysmal and sinus)|

| Supraventricular|

* Atrial
* Multifocal
* Junctional
* AV nodal reentrant
* Junctional ectopic

|

Ventricular|

* Accelerated idioventricular rhythm
* Catecholaminergic polymorphic
* Torsades de pointes

Premature contraction|

* Atrial
* Junctional
* Ventricular

Pre-excitation syndrome|

* Lown–Ganong–Levine
* Wolff–Parkinson–White

Flutter / fibrillation|

* Atrial flutter
* Ventricular flutter
* Atrial fibrillation
* Familial
* Ventricular fibrillation

Pacemaker|

* Ectopic pacemaker / Ectopic beat
* Multifocal atrial tachycardia
* Pacemaker syndrome
* Parasystole
* Wandering atrial pacemaker

Long QT syndrome|

* Andersen–Tawil
* Jervell and Lange-Nielsen
* Romano–Ward

Cardiac arrest|

* Sudden cardiac death
* Asystole
* Pulseless electrical activity
* Sinoatrial arrest

Other / ungrouped|

* hexaxial reference system
* Right axis deviation
* Left axis deviation
* QT
* Short QT syndrome
* T
* T wave alternans
* ST
* Osborn wave
* ST elevation
* ST depression
* Strain pattern

Cardiomegaly|

* Ventricular hypertrophy
* Left
* Right / Cor pulmonale
* Atrial enlargement
* Left
* Right
* Athletic heart syndrome

Other|

* Cardiac fibrosis
* Heart failure
* Diastolic heart failure
* Cardiac asthma
* Rheumatic fever

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