Letter to the Editor
How should we interpret the athlete's electrocardiogram?
Como interpretar o eletrocardiograma do atleta?
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Top: J-point elevation preceding T-wave inversion (both panels from healthy athletes); middle: ST-segment elevation (without J-point elevation) preceding T-wave inversion (both panels from patients with hypertrophic cardiomyopathy); bottom: ST-segment elevation (without J-point elevation) preceding T-wave inversion (both panels from patients with arrhythmogenic right ventricular cardiomyopathy). Arrows indicate the J-point. ARVC: arrhythmogenic right ventricular cardiomyopathy; HCM: hypertrophic cardiomyopathy. Adapted from Calore et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> with permission from Oxford University Press.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ricardo C. Rodrigues, Gomes Serrão, Susana Gomes, Décio Pereira" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Ricardo C." 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Top: J-point elevation preceding T-wave inversion (both panels from healthy athletes); middle: ST-segment elevation (without J-point elevation) preceding T-wave inversion (both panels from patients with hypertrophic cardiomyopathy); bottom: ST-segment elevation (without J-point elevation) preceding T-wave inversion (both panels from patients with arrhythmogenic right ventricular cardiomyopathy). Arrows indicate the J-point. ARVC: arrhythmogenic right ventricular cardiomyopathy; HCM: hypertrophic cardiomyopathy. Adapted from Calore et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> with permission from Oxford University Press.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ricardo C. Rodrigues, Gomes Serrão, Susana Gomes, Décio Pereira" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Ricardo C." 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"tieneTextoCompleto" => true "saludo" => "To the editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "715" "paginaFinal" => "716" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Hélder Dores, Nuno Cardim" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Hélder" "apellidos" => "Dores" "email" => array:1 [ 0 => "heldores@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Nuno" "apellidos" => "Cardim" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Hospital das Forças Armadas, Lisboa, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Cardiologia Desportiva e Miocardiopatias (CCDM), Hospital da Luz, Lisboa, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "NOVA Medical School/Faculdade de Ciências Médicas – Universidade Nova de Lisboa, Lisboa, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Como interpretar o eletrocardiograma do atleta?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">It was with considerable interest that we read the recent article by Machado and Silva<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> entitled “Benign and pathological electrocardiographic changes in athletes”, a comprehensive and pertinent review. Interpretation of the athlete's echocardiogram (ECG) remains the subject of debate, but beyond the ongoing ‘transatlantic’ discussion on whether the ECG should be included in pre-participation screening, the basic question remains: how should we interpret the athlete's ECG?<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">As Machado and Silva point out, the European Society of Cardiology (ESC) criteria are associated with a high false-positive rate, and so there is a need for more restrictive criteria. Among these are the Seattle criteria, which the article states are the latest recommendations for the interpretation of the ECG in athletes. We would like to put forward certain points that in our opinion will add to the discussion.<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">(1)</span><p id="par0015" class="elsevierStylePara elsevierViewall">The Seattle criteria are a valuable aid to interpreting the athlete's ECG, but it should be borne in mind that they are only a consensus document based on expert opinion, and are not evidence-based.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">(2)</span><p id="par0020" class="elsevierStylePara elsevierViewall">After the publication of the Seattle criteria, Sheikh et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> proposed the ‘refined’ criteria. Although these are mentioned in the article by Machado and Vaz Silva, they should, in our opinion, have received greater attention, for three reasons. Firstly, they are based on the analysis of a large sample of elite athletes, and their accuracy was validated in a population of athletes with hypertrophic cardiomyopathy. Secondly, they assume, on the basis of previously published research, that some isolated ECG findings are probably physiological (such as axis deviation or atrial dilatation). Thirdly, they reduce the number of false positives, even compared to the Seattle criteria.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3–5</span></a> In our experience at the Hospital das Forças Armadas and Hospital da Luz, use of the ‘refined’ criteria instead of the ESC criteria has reduced the false-positive rate by two-thirds.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">(3)</span><p id="par0025" class="elsevierStylePara elsevierViewall">As pointed out in the article, even when more specific criteria are applied, variability in interpretation of the ECG remains high. In a study of Portuguese cardiologists, soon to be published, this was around 25%.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">(4)</span><p id="par0030" class="elsevierStylePara elsevierViewall">Another reason for the difficulty in standardizing interpretation of the athlete's ECG is that the same alteration may be defined differently in different criteria. Thus, pathological Q waves are defined as >4 mm deep in any lead except III and aVR in the ESC criteria, >3 mm deep or >40 ms duration in ≥2 contiguous leads except III and aVR in the Seattle criteria, and ≥40 ms in duration or ≥25% of the height of the ensuing R wave in the ‘refined’ criteria.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p></li></ul></p><p id="par0035" class="elsevierStylePara elsevierViewall">This long-standing debate makes it essential to develop specific structures for the assessment of athletes and for sports cardiology in general. This will make it easier to standardize procedures and to develop multicenter projects that could reduce the ‘gray zone’ that still prevails around this subject, which would have a significant impact at various levels.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Dores H, Cardim N. Como interpretar o eletrocardiograma do atleta? Rev Port Cardiol. 2016;35:715–716.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Alterações eletrocardiográficas benignas e patológicas em atletas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Machado" 1 => "M. Vaz Silva" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2015.07.007" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2015" "volumen" => "34" "paginaInicial" => "753" "paginaFinal" => "770" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26643438" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The hearts of competitive athletes: an up-to-date overview of exercise-induced cardiac adaptations" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "H. Dores" 1 => "A. Freitas" 2 => "A. 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Ghani" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.113.006179" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2014" "volumen" => "129" "paginaInicial" => "1637" "paginaFinal" => "1649" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24619464" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of three current sets of electrocardiographic interpretation criteria for use in screening athletes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "N.R. Riding" 1 => "N. Sheikh" 2 => "C. Adamuz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Heart" "fecha" => "2014" "paginaInicial" => "1" "paginaFinal" => "7" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Should axis deviation or atrial enlargement be categorised as abnormal in young athletes? The athlete's electrocardiogram: time for re-appraisal of markers of pathology" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Gati" 1 => "N. Sheikh" 2 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 5 | 20 |
| 2024 October | 51 | 28 | 79 |
| 2024 September | 50 | 25 | 75 |
| 2024 August | 42 | 25 | 67 |
| 2024 July | 35 | 35 | 70 |
| 2024 June | 45 | 19 | 64 |
| 2024 May | 30 | 19 | 49 |
| 2024 April | 37 | 34 | 71 |
| 2024 March | 39 | 18 | 57 |
| 2024 February | 27 | 16 | 43 |
| 2024 January | 30 | 29 | 59 |
| 2023 December | 24 | 31 | 55 |
| 2023 November | 33 | 33 | 66 |
| 2023 October | 20 | 13 | 33 |
| 2023 September | 21 | 17 | 38 |
| 2023 August | 18 | 20 | 38 |
| 2023 July | 23 | 7 | 30 |
| 2023 June | 28 | 16 | 44 |
| 2023 May | 34 | 26 | 60 |
| 2023 April | 22 | 4 | 26 |
| 2023 March | 32 | 23 | 55 |
| 2023 February | 24 | 23 | 47 |
| 2023 January | 19 | 10 | 29 |
| 2022 December | 28 | 18 | 46 |
| 2022 November | 48 | 37 | 85 |
| 2022 October | 33 | 37 | 70 |
| 2022 September | 31 | 29 | 60 |
| 2022 August | 28 | 34 | 62 |
| 2022 July | 30 | 42 | 72 |
| 2022 June | 30 | 36 | 66 |
| 2022 May | 22 | 31 | 53 |
| 2022 April | 34 | 37 | 71 |
| 2022 March | 32 | 39 | 71 |
| 2022 February | 25 | 32 | 57 |
| 2022 January | 26 | 30 | 56 |
| 2021 December | 26 | 36 | 62 |
| 2021 November | 41 | 32 | 73 |
| 2021 October | 38 | 43 | 81 |
| 2021 September | 25 | 33 | 58 |
| 2021 August | 43 | 28 | 71 |
| 2021 July | 22 | 21 | 43 |
| 2021 June | 32 | 21 | 53 |
| 2021 May | 42 | 38 | 80 |
| 2021 April | 66 | 24 | 90 |
| 2021 March | 69 | 22 | 91 |
| 2021 February | 62 | 18 | 80 |
| 2021 January | 39 | 17 | 56 |
| 2020 December | 42 | 15 | 57 |
| 2020 November | 30 | 13 | 43 |
| 2020 October | 37 | 17 | 54 |
| 2020 September | 70 | 17 | 87 |
| 2020 August | 22 | 10 | 32 |
| 2020 July | 48 | 12 | 60 |
| 2020 June | 40 | 11 | 51 |
| 2020 May | 38 | 8 | 46 |
| 2020 April | 41 | 14 | 55 |
| 2020 March | 62 | 12 | 74 |
| 2020 February | 65 | 38 | 103 |
| 2020 January | 28 | 6 | 34 |
| 2019 December | 46 | 8 | 54 |
| 2019 November | 44 | 8 | 52 |
| 2019 October | 38 | 8 | 46 |
| 2019 September | 31 | 6 | 37 |
| 2019 August | 35 | 12 | 47 |
| 2019 July | 56 | 9 | 65 |
| 2019 June | 35 | 20 | 55 |
| 2019 May | 42 | 9 | 51 |
| 2019 April | 50 | 13 | 63 |
| 2019 March | 107 | 8 | 115 |
| 2019 February | 69 | 6 | 75 |
| 2019 January | 102 | 10 | 112 |
| 2018 December | 103 | 15 | 118 |
| 2018 November | 48 | 9 | 57 |
| 2018 October | 67 | 12 | 79 |
| 2018 September | 72 | 16 | 88 |
| 2018 August | 33 | 12 | 45 |
| 2018 July | 17 | 3 | 20 |
| 2018 June | 47 | 4 | 51 |
| 2018 May | 40 | 12 | 52 |
| 2018 April | 61 | 6 | 67 |
| 2018 March | 69 | 11 | 80 |
| 2018 February | 47 | 8 | 55 |
| 2018 January | 55 | 6 | 61 |
| 2017 December | 80 | 4 | 84 |
| 2017 November | 71 | 12 | 83 |
| 2017 October | 45 | 11 | 56 |
| 2017 September | 35 | 15 | 50 |
| 2017 August | 49 | 11 | 60 |
| 2017 July | 22 | 4 | 26 |
| 2017 June | 34 | 14 | 48 |
| 2017 May | 31 | 13 | 44 |
| 2017 April | 20 | 3 | 23 |
| 2017 March | 28 | 16 | 44 |
| 2017 February | 44 | 16 | 60 |
| 2017 January | 48 | 20 | 68 |
| 2016 December | 94 | 28 | 122 |
| 2016 November | 6 | 11 | 17 |
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