Recommendations for Interpretation of 12-Lead ECG in the Athlete
Recommendations for Interpretation of 12-Lead ECG in the Athlete
Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed.
Regular sports participation is encouraged by the medical community as part of cardiovascular prevention measures, because it improves fitness and reduces cardiovascular morbidity and mortality worldwide. A large proportion of the young population participates in competitive or recreational sports activity. The 12-lead electrocardiogram (ECG) is an established tool in the evaluation of athletes, providing important diagnostic and prognostic information on a variety of cardiovascular diseases which are associated with an increased risk of sudden cardiac death (SCD) during sports. Physicians are frequently asked to interpret an ECG in the setting of cardiovascular evaluation of athletes. Standard criteria for defining the limits of normal (or variation of normal) ECG in the athlete remain to be determined. The interpretation of the athlete's ECG is often left to personal experience and usually made according to traditional ECG criteria used in the general (non-athletic) population.
Electrocardiogram changes in athletes are common and usually reflect structural and electrical remodelling of the heart as an adaptation to regular physical training (athlete's heart). However, abnormalities of athlete's ECG may be an expression of an underlying heart disease which carries a risk of SCD during sport. It is important that ECG abnormalities resulting from intensive physical training and those potentially associated with an increased cardiovascular risk are correctly distinguished.
Errors in differentiating between physiological and pathological ECG abnormalities may have serious consequences. Athletes may undergo expensive diagnostic work-up or may be unnecessarily disqualified from competition for changes that fall within the normal range for athletes. This is of particular relevance for professional athletes in whom disqualification from competitive sports has significant financial and psychological consequences. Alternatively, signs of potentially lethal cardiovascular disorders may be misinterpreted as normal variants of an athlete's ECG. A correct evaluation of 12-lead ECG patterns in the athlete and appropriate subsequent action has the potential to increase efficacy, accuracy, and cost-effectiveness of athlete's cardiovascular evaluation.
Some consider that physiological ECG changes overlap significantly with ECG abnormalities seen in the cardiovascular diseases which cause SCD in the young. The ECG has therefore been considered a non-specific and non-cost-effective tool for cardiovascular evaluation of athletes because of a presumed high level of false-positive results. This concept was based on few studies of small and selected series of highly trained athletes from a limited number of sports disciplines. The 25-year Italian experience with universal pre-participation screening has offered the unique opportunity to investigate ECG changes in large cohorts of athletes, engaged in a broad variety of sports activities with different and well-characterized levels of training and fitness. The currently available data allow an accurate redefinition of the spectrum of athlete's ECG patterns and raise the need for a revision of accuracy, utility, and cost–benefit analysis of the use of ECG in the cardiovascular evaluation of the athlete. In addition, there is growing experience of early and incomplete disease expression of the inherited cardiomyopathies and arrhythmias which usually have ECG changes as their initial presentation.
The present document is endorsed by the Sections of Sports Cardiology and Exercise Physiology of the European Association of Cardiovascular Prevention and Rehabilitation and by the Working Group on Myocardial and Pericardial diseases of the European Society of Cardiology and represents the position statement of an international panel of cardiologists and sports medical doctors with expertise in the field of cardiovascular evaluation of young competitive athletes. The article provides a modern approach to interpretation of 12-lead ECG in the athlete based on recently published new findings. The target audience are primarily sports medical doctors, sports cardiologists, and team physicians. The main objective is to differentiate between physiological adaptive ECG changes and pathological ECG abnormalities, with the aim to prevent adaptive changes in the athlete being erroneously attributed to heart disease, or signs of life-threatening cardiovascular conditions being dismissed as normal variants of athlete's heart. Because only pathological ECG abnormalities cause alarm and require action with additional testing to exclude (or confirm) the suspect of a lethal cardiovascular disorder, appropriate interpretation of an athlete's ECG also results in a considerable cost savings in the context of a population-based pre-participation screening program.
The document provides guided clinical evaluation of the athletes with ECG abnormalities. For every ECG abnormality, the document focuses on the recommended clinical work-up for differential diagnosis and clinical assessment. When indicated the referral options for risk stratification and cardiovascular management are briefly addressed, although for more detailed and elaborated recommendations concerning eligibility for sports participation we refer to other specific guidelines. The document is also aimed to update general cardiologists and sports medical physicians with the clinically relevant information which can be obtained from ECG in the athlete.
Abstract and Introduction
Abstract
Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed.
Introduction
Regular sports participation is encouraged by the medical community as part of cardiovascular prevention measures, because it improves fitness and reduces cardiovascular morbidity and mortality worldwide. A large proportion of the young population participates in competitive or recreational sports activity. The 12-lead electrocardiogram (ECG) is an established tool in the evaluation of athletes, providing important diagnostic and prognostic information on a variety of cardiovascular diseases which are associated with an increased risk of sudden cardiac death (SCD) during sports. Physicians are frequently asked to interpret an ECG in the setting of cardiovascular evaluation of athletes. Standard criteria for defining the limits of normal (or variation of normal) ECG in the athlete remain to be determined. The interpretation of the athlete's ECG is often left to personal experience and usually made according to traditional ECG criteria used in the general (non-athletic) population.
Electrocardiogram changes in athletes are common and usually reflect structural and electrical remodelling of the heart as an adaptation to regular physical training (athlete's heart). However, abnormalities of athlete's ECG may be an expression of an underlying heart disease which carries a risk of SCD during sport. It is important that ECG abnormalities resulting from intensive physical training and those potentially associated with an increased cardiovascular risk are correctly distinguished.
Errors in differentiating between physiological and pathological ECG abnormalities may have serious consequences. Athletes may undergo expensive diagnostic work-up or may be unnecessarily disqualified from competition for changes that fall within the normal range for athletes. This is of particular relevance for professional athletes in whom disqualification from competitive sports has significant financial and psychological consequences. Alternatively, signs of potentially lethal cardiovascular disorders may be misinterpreted as normal variants of an athlete's ECG. A correct evaluation of 12-lead ECG patterns in the athlete and appropriate subsequent action has the potential to increase efficacy, accuracy, and cost-effectiveness of athlete's cardiovascular evaluation.
Some consider that physiological ECG changes overlap significantly with ECG abnormalities seen in the cardiovascular diseases which cause SCD in the young. The ECG has therefore been considered a non-specific and non-cost-effective tool for cardiovascular evaluation of athletes because of a presumed high level of false-positive results. This concept was based on few studies of small and selected series of highly trained athletes from a limited number of sports disciplines. The 25-year Italian experience with universal pre-participation screening has offered the unique opportunity to investigate ECG changes in large cohorts of athletes, engaged in a broad variety of sports activities with different and well-characterized levels of training and fitness. The currently available data allow an accurate redefinition of the spectrum of athlete's ECG patterns and raise the need for a revision of accuracy, utility, and cost–benefit analysis of the use of ECG in the cardiovascular evaluation of the athlete. In addition, there is growing experience of early and incomplete disease expression of the inherited cardiomyopathies and arrhythmias which usually have ECG changes as their initial presentation.
The present document is endorsed by the Sections of Sports Cardiology and Exercise Physiology of the European Association of Cardiovascular Prevention and Rehabilitation and by the Working Group on Myocardial and Pericardial diseases of the European Society of Cardiology and represents the position statement of an international panel of cardiologists and sports medical doctors with expertise in the field of cardiovascular evaluation of young competitive athletes. The article provides a modern approach to interpretation of 12-lead ECG in the athlete based on recently published new findings. The target audience are primarily sports medical doctors, sports cardiologists, and team physicians. The main objective is to differentiate between physiological adaptive ECG changes and pathological ECG abnormalities, with the aim to prevent adaptive changes in the athlete being erroneously attributed to heart disease, or signs of life-threatening cardiovascular conditions being dismissed as normal variants of athlete's heart. Because only pathological ECG abnormalities cause alarm and require action with additional testing to exclude (or confirm) the suspect of a lethal cardiovascular disorder, appropriate interpretation of an athlete's ECG also results in a considerable cost savings in the context of a population-based pre-participation screening program.
The document provides guided clinical evaluation of the athletes with ECG abnormalities. For every ECG abnormality, the document focuses on the recommended clinical work-up for differential diagnosis and clinical assessment. When indicated the referral options for risk stratification and cardiovascular management are briefly addressed, although for more detailed and elaborated recommendations concerning eligibility for sports participation we refer to other specific guidelines. The document is also aimed to update general cardiologists and sports medical physicians with the clinically relevant information which can be obtained from ECG in the athlete.
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