Interpreting the Athlete's EKG: Are All Repolarization Anomalies Created Equal?
Ad Ad ddr dr dres ess fo for r r Co Co C rr rr rres esp po on nd nden n nce ce e: : : Sanj nj jay ay y Sha harma, a, , BSc Sc ( ( (Hons ns) , ), ), M MBC BChB, , , MD MD, , , FR FRCP CP Prof o es esso sor of of f C C Cli li lini ni ica cal l l Ca Ca C rd rdio io i lo lo l gy gy by guest on 2 The electrical manifestations of athletic training have been described in large athletic populations consisting predominantly of young, Caucasian (white), male athletes, competing in a variety of sports.
... riety of sports. The 2010 European Society of Cardiology (ESC) recommendations attempted to differentiate between EKG features suggestive of athletic training (type-1 changes), from those that may be indicative of cardiac disease (type-2 changes) and warrant further investigation. 1 Over the past decade the utility of EKG based pre-participation cardiac evaluation has gained recognition among a number of sporting organizations and type-2 EKG patterns are likely to prompt the referral of an increasing number of athletes for comprehensive evaluation prior to clearance to compete. As such, the development of EKG criteria that are highly sensitive and specific is of paramount importance to ensure that the majority of athletes at potential risk of sudden cardiac death are identified, while minimizing unnecessary investigations or the risk of an erroneous diagnosis. The initial estimated prevalence of type-2 changes in the athlete's EKG was 5% but several subsequent studies have demonstrated that this figure is a gross underestimate. When the additive effect of various demographic factors such as the age, sex, sporting discipline, body habitus and ethnicity of the athlete are taken into consideration the prevalence of type-2 EKG changes is as high as 40% in certain groups. 2 Such figures portray the EKG as a poor tool for discriminating between cardiac physiology and pathology, given that most type-2 EKG patterns do not amount to a diagnosis following investigation (false positives). Since the publication of the ESC criteria in 2010, there have been a number of studies in large athletic cohorts, which should lead to the formulation of an evidence-based revision of the existing criteria for the interpretation of the athlete's EKG in the near future. Such studies indicate that T-wave inversions in leads V1-V4 in athletes of African/Afro-Caribbean origin (black athletes), pecific is of paramount importance to ensure that the majority of athlet t es at pote te ent ntia ia i l l ri ri risk sk sk o o of f f udden cardiac death are identified, while minimizing unnecessary investigations or the risk of an n e e err rr rron on oneo eo ous us u dia agn gn gnos o is. The in nit itia ia ial es sti ti tima ma ate te ted d d pr pr prev eval al a e en enc ce o of ty y yp p pe-2 c ch han n ng ge ges s in in i t the he a ath thle let te te's s E E EKG KG KG w was as a 5 5% % % bu bu but t e eve ve vera ra ral l l su subs bs bse eq eque ue ent t t s stu tu udi di ies es h hav av a e e e de de demo m mon ns nstr tr trat at ated ed ed t t tha ha hat t t t thi h s s s fi fi figu gu gure re i i is s a a a gr gr gros os o s s s t u un unde de dere re est stim im ma at ate. . W W Whe hen n n t th the additive effec ect t t of of o v v var ar a io io ous u u d d dem em emog g gra ra raph ph phic c c f f fac ac acto to ors rs rs su su such ch ch a a as s th th the e ag ag age, e, e, s s sex e e , , , sp sp spor or orti ti ting ng ng d d dis is isci ci cipl pl plin in ne, e body by guest on arm rma a S. S. Cl Cl Clin in inic ical al a s s sig ig ign n nifi fi fica ca c nc nc nce e o of of e e ele le lect ctr r roc oc o ar ar a di di diog og ogra rap ph phic ic ic r r rig ig ight ht ht v v ven nt t tri ic cul ula a ar hype pert rtroph phy y in n a ath hle lete tes: c com ompa pari riso son with th a arr rrhy hyt thm hmog gen enic ic r rig ight ht v ven entr tric icul u ar ar c car ardi diom o yo yopa path thy y an and d pulmonary hy hy hype pe pert rt ten en ensi sion on on. Eu Eu Eur r r He He Hear ar a t t t J J