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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Repeated exercise training induces various cardiovascular adaptations that can manifest as changes in the resting 12-lead electrocardiogram &#40;ECG&#41;&#46; These changes can be classified as pathological in non-athletic individuals but considered physiological and training-related in athletes&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> However&#44; evaluation of the athlete&#39;s ECG is challenging because various physiological adaptations can overlap with conditions associated with an increased risk of sudden cardiac death&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The prevalence&#44; pattern and degree of ECG changes are not uniform among athletes and are dependent on various factors including age&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2&#44;3</span></a> gender<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4&#8211;6</span></a> and ethnicity&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">7&#44;8</span></a> Although a higher prevalence of marked ECG changes has been reported in athletes engaged in high-intensity endurance sports&#44; the association between the type of sport and the occurrence of abnormal ECG findings in athletes is not well established&#46; The majority of existing studies reporting ECG changes according to the type of sport were performed in small populations&#44; mainly covering endurance disciplines&#44; and did not include sports characterized by different loading conditions&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2&#44;9&#44;10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The conventional dual division between endurance&#47;dynamic and static&#47;strength sports seems rather simplistic&#46; Many sporting disciplines combine elements of both types of exercise&#44; and it can therefore be difficult to establish which is predominant&#46; Additionally&#44; factors such as duration of training and emotional stress related to competition are not taken into consideration&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The purpose of the study was to assess the association between intensity of sport and level of competition with the presence of abnormal ECG findings in athletes&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Athletes</span><p id="par0025" class="elsevierStylePara elsevierViewall">Between September 2006 and July 2012&#44; 15<span class="elsevierStyleHsp" style=""></span>175 young individuals &#40;aged between 14 and 35 years&#41; underwent cardiac evaluation in the UK&#44; as part of a pre-participation screening program established by the charitable organization Cardiac Risk in the Young&#46; For the purpose of this study selected athletes were defined as individuals involved in regular competition &#40;regional&#44; national or international&#41; and training more than four hours per week&#46; The final population comprised 3423 athletes&#46; Cardiac evaluation consisted of a self-report health questionnaire&#44; physical examination and a 12-lead ECG&#46; On an individual basis&#44; when indicated for clinical reasons&#44; ECG abnormalities or research&#44; transthoracic echocardiography was also performed&#46; All the athletes included in this analysis were asymptomatic and normotensive at rest &#40;&#60;140&#47;90 mmHg&#41;&#46; Ethnicity&#44; number of hours of exercise-training&#47;week and level of competition were self-assigned&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">12-lead electrocardiogram</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 12-lead ECG was performed using GE<span class="elsevierStyleSup">&#174;</span> Marquette Hellige &#40;Milwaukee&#44; WI&#44; USA&#41; or Philips<span class="elsevierStyleSup">&#174;</span> Pagewriter Trim III &#40;Bothell&#44; WA&#44; USA&#41; electrocardiographs&#44; with a paper speed of 25 mm&#47;s and amplification of 0&#46;1 mV&#47;mm&#44; as previously described&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> Heart rate and QRS axis were calculated&#59; intervals&#44; durations&#44; and voltages were measured in each lead&#46; The ECGs were analyzed by the cardiologist responsible for each screening session and later read independently by two cardiologists&#44; highly experienced in sports cardiology&#44; cardiomyopathies and primary electrical cardiac diseases&#46; All ECGs were interpreted and categorized as normal &#40;without changes or with training-related changes&#41; or abnormal &#40;with changes that justified additional investigations for exclusion of cardiac pathology&#41; in accordance with the Seattle criteria &#40;SC&#41; and the Refined Criteria &#40;RC&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">13&#8211;16</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Transthoracic echocardiogram</span><p id="par0035" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography was performed by a cardiologist or a senior cardiac physiologist&#44; using a Philips<span class="elsevierStyleSup">&#174;</span> Sonos 7500&#44; Philips<span class="elsevierStyleSup">&#174;</span> iE33&#44; or Philips<span class="elsevierStyleSup">&#174;</span> CPX50 &#40;Bothell&#44; WA&#44; USA&#41; and Acuson Computed Sono-graph<span class="elsevierStyleSup">&#174;</span> 128XP&#47;10c &#40;San Jose&#44; CA&#44; USA&#41;&#46; Standard views and chamber measurements were performed as previously suggested&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> Left ventricular wall thickness was measured in two-dimensional &#40;2D&#41; parasternal short axis&#44; at the level of the mitral valve and papillary muscles&#44; and right ventricular dimensions were measured in apical 4-chamber view and right ventricular outflow in parasternal short-axis view at the aortic valve level&#46; Color tissue Doppler and 2D continuous and pulsed Doppler were performed using standard parasternal and apical views&#46; Assessment of diastolic function included pulsed Doppler across the mitral valve and tissue Doppler velocity imaging of the septal and lateral mitral valve annulus and free wall tricuspid valve annulus&#46; An experienced cardiac physiologist independently repeated all cardiac measurements&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Classification of sports</span><p id="par0040" class="elsevierStylePara elsevierViewall">The sporting disciplines of all the athletes included in the study were categorized according to the classification proposed by Mitchel et al&#46; in the 36th Bethesda Conference guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> This classification is based on the peak of static and dynamic components achieved during exercise&#44; evaluated by maximal oxygen uptake and maximal voluntary contraction&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The volume of training was analyzed according to the number of hours performed per week and the competitive level was stratified according to the nature of the competition &#8211; regional&#44; national or international&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The following categories were formulated&#44; according to which the distribution of abnormal ECG changes was analyzed&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Intensity of sport&#58; low&#47;moderate vs&#46; at least one high static or dynamic component &#40;categories III and&#47;or C of the Mitchell et al&#46; classification&#41;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Competitive level&#58; regional vs&#46; national&#47;international</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Training volume&#58; &#8804;20 vs&#46; &#62;20 hours&#47;week</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Type of sport&#58; high static vs&#46; high dynamic component&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical approval and consent</span><p id="par0075" class="elsevierStylePara elsevierViewall">Written consent was obtained from individuals aged 16 years or over and from a parent for those aged less than 16 years&#46; The National Research Ethics Service&#44; Essex 2 Research Ethics Committee&#44; granted ethical approval in the UK&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">Continuous variables with normal distribution were expressed as means and standard deviations&#46; Normality was tested with the Kolmogorov-Smirnov test&#46; Categorical variables were expressed as frequencies and percentages&#46; Statistical comparison of baseline characteristics was performed using the chi-square test or Fisher&#39;s exact test&#44; when appropriate&#44; and the Student&#39;s t test or the Mann-Whitney test for continuous variables&#46; To identify independent predictors of abnormal SC&#44; multivariate analysis using a binary logistic regression model &#40;enter method&#41; was performed&#46; Two-tailed tests of significance are reported&#46; For all comparisons&#44; a p value of &#60;0&#46;05 was considered statistically significant&#46; When appropriate&#44; 95&#37; confidence intervals &#40;CI&#41; were calculated&#46; The statistical analysis was performed with SPSS version 21&#46;0 &#40;SPSS<span class="elsevierStyleSup">&#174;</span> Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Baseline characteristics</span><p id="par0085" class="elsevierStylePara elsevierViewall">Of the 3423 athletes included in the final analysis&#44; mean age was 20&#46;1&#177;5&#46;0 years&#44; 2468 &#40;72&#46;1&#37;&#41; were male and the majority were Caucasian &#40;90&#46;1&#37;&#41;&#46; Athletes were engaged in 43 sporting disciplines&#44; with rugby &#40;35&#46;0&#37;&#41;&#44; football &#40;9&#46;7&#37;&#41;&#44; swimming &#40;6&#46;3&#37;&#41; and rowing&#47;canoeing &#40;4&#46;6&#37;&#41; being the most popular sports&#46; Almost half of the overall population &#40;46&#46;3&#37;&#41; were engaged in sports with a high static and&#47;or high dynamic component &#40;category III and&#47;or C&#41;&#46; Regarding the competitive level&#44; 795 &#40;23&#46;2&#37;&#41; athletes were involved in regional&#44; 1277 &#40;37&#46;3&#37;&#41; in national and 1352 &#40;39&#46;5&#37;&#41; in international competitions&#46; The mean number of training hours&#47;week was 16&#46;2&#177;7&#46;7 &#40;5-50 hours&#41;&#44; with 714 &#40;20&#46;9&#37;&#41; of athletes training for &#62;20 hours&#47;week&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Electrocardiographic findings</span><p id="par0090" class="elsevierStylePara elsevierViewall">Based on the SC&#44; approximately 80&#37; of the overall population &#40;n&#61;2731&#41; had alterations in the 12-lead ECG&#58; normal&#47;training-related in 2482 &#40;72&#46;5&#37;&#41; and abnormal&#47;training-unrelated in 225 &#40;6&#46;6&#37;&#41; athletes&#46; Among the abnormal ECG changes&#44; the most prevalent were left atrial enlargement in 76 athletes &#40;2&#46;1&#37;&#41;&#44; left axis deviation in 47 &#40;1&#46;4&#37;&#41;&#44; T-wave inversions in 42 &#40;1&#46;2&#37;&#41; and Wolff-Parkinson White pattern in 28 &#40;0&#46;01&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; These abnormal ECG findings were more frequent in athletes involved in high-intensity sports &#40;8&#46;0&#37; vs&#46; 5&#46;4&#37;&#59; p&#61;0&#46;002&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#41;&#46; Athletes with abnormal SC were more likely to be of Black&#47;Caribbean descendent &#40;8&#46;0&#37; vs&#46; 5&#46;0&#37;&#59; p&#61;0&#46;047&#41; and to compete at national&#47;international level &#40;82&#46;7&#37; vs&#46; 76&#46;3&#37;&#59; p&#61;0&#46;028&#41; in sports with a high static or dynamic component &#40;56&#46;0&#37; vs&#46; 45&#46;6&#37;&#59; p&#61;0&#46;002&#41;&#46; Athletes involved in disciplines with predominantly high dynamic intensity &#40;classes C&#8211;I&#47;II&#41; had a higher rate of abnormal ECG changes &#40;9&#46;1&#37; vs&#46; 5&#46;5&#37;&#59; p&#60;0&#46;001&#41;&#44; but there was no significant difference in sports with high static intensity &#40;III-A&#47;B&#41; &#40;4&#46;5&#37; vs&#46; 6&#46;7&#37;&#59; p&#61;0&#46;153&#41;&#46; Comparing only athletes involved in disciplines with isolated high dynamic intensity &#40;classes C-I&#47;II&#41; with those in high static intensity &#40;classes III-A&#47;B&#41;&#44; the former had a higher rate of abnormal ECG changes &#40;9&#46;1&#37; vs&#46; 4&#46;5&#37;&#59; p&#61;0&#46;014&#41;&#46; Exercising &#62;20 hours&#47;week was not significantly associated with the presence of abnormal ECG changes &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">By multivariate analysis&#44; national&#47;international level &#40;odds ratio &#91;OR&#93; 1&#46;50&#44; 95&#37; confidence interval &#91;CI&#93; 1&#46;04-2&#46;14&#59; p&#61;0&#46;027&#41; and high-intensity sport &#40;OR 1&#46;55&#44; 1&#46;18-2&#46;03&#59; p&#61;0&#46;002&#41; were independent predictors of abnormal ECG changes&#44; with a trend for Black&#47;Caribbean ethnicity &#40;OR 1&#46;58&#44; 95&#37; CI 0&#46;95-2&#46;62&#59; p&#61;0&#46;078&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">Table 3</a>&#41;&#46; The combination of the two independent variables revealed a significantly higher frequency of abnormal ECG findings in athletes competing in high-intensity sports at national&#47;international level &#40;8&#46;7&#37; vs&#46; 5&#46;5&#37;&#59; p&#60;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A&#41;&#46;</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Interpretation of ECGs with the RC led to a decrease of more than half in the number of abnormal&#47;training-unrelated ECG changes&#44; to 103 &#40;3&#46;0&#37;&#41; athletes&#44; including among those involved in high-intensity sports &#40;4&#46;2&#37; vs&#46; 2&#46;0&#37;&#59; p&#60;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41;&#46; These athletes with abnormal RC were more likely to be female &#40;47&#46;6&#37; vs&#46; 27&#46;3&#37;&#59; &#60;0&#46;001&#41; and to be involved in disciplines with predominantly high dynamic intensity &#40;classes C-I&#47;II&#41; &#40;4&#46;7&#37; vs&#46; 2&#46;3&#37;&#59; p&#60;0&#46;001&#41;&#44; but there was no significant difference in disciplines with predominantly high static intensity &#40;III-A&#47;B&#41; &#40;2&#46;6&#37; vs&#46; 3&#46;0&#37;&#59; p&#61;0&#46;700&#41;&#46; Comparing only athletes involved in disciplines with isolated high dynamic intensity &#40;classes C-I&#47;II&#41; with those in high static intensity &#40;classes III-A&#47;B&#41;&#44; there was no significant difference in prevalence of abnormal ECG changes &#40;4&#46;7&#37; vs&#46; 2&#46;6&#37;&#59; p&#61;0&#46;127&#41;&#46; Competing at national&#47;international level &#40;82&#46;5&#37; vs&#46; 76&#46;6&#37;&#59; p&#61;0&#46;161&#41; and training &#62;20 hours&#47;week &#40;19&#46;4&#37; vs&#46; 20&#46;9&#37;&#59; p&#61;0&#46;715&#41; were not significantly associated with abnormal RC&#46; However&#44; the combination of intensity of sport and competitive level revealed significant abnormal ECG changes in athletes involved in high-intensity sports at national&#47;international level &#40;4&#46;7&#37; vs&#46; 2&#46;1&#37;&#59; p&#60;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Transthoracic echocardiography</span><p id="par0105" class="elsevierStylePara elsevierViewall">Of the overall population&#44; 1345 &#40;39&#46;3&#37;&#41; athletes underwent transthoracic echocardiography&#46; Structural findings were interpreted as abnormal in 26 &#40;0&#46;8&#37;&#41; athletes&#46; The echocardiographic findings classified as abnormal were aortic bicuspid valve &#40;n&#61;7&#41;&#44; isolated right ventricular changes &#40;e&#46;g&#46; hypertrabeculation&#41; &#40;n&#61;5&#41;&#44; mitral valve prolapse &#40;n&#61;4&#41;&#44; anomalous coronary origin &#40;n&#61;2&#41;&#44; dilated aortic root &#40;n&#61;2&#41;&#44; left ventricular hypertrophy with interventricular septum &#8805;15 mm &#40;n&#61;1&#41;&#44; large patent foramen ovale &#40;n&#61;1&#41;&#44; tricuspid valve prolapse &#40;n&#61;1&#41;&#44; pulmonary valve stenosis &#40;n&#61;1&#41;&#44; atrial septal defect &#40;n&#61;1&#41; and cor triatriatum &#40;n&#61;1&#41;&#46; These structural alterations were more frequent in athletes with both abnormal SC &#40;2&#46;7&#37; vs&#46; 0&#46;6&#37;&#59; p&#61;0&#46;010&#41; and abnormal RC &#40;3&#46;9&#37; vs&#46; 0&#46;7&#37;&#59; p&#60;0&#46;001&#41;&#46; A higher frequency of echocardiographic changes classified as abnormal was also evident in athletes engaged in high-intensity sports and competing at national&#47;international level &#40;1&#46;3&#37; vs&#46; 0&#46;5&#37;&#59; p&#61;0&#46;012&#41;&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">In the large cohort of competitive athletes under analysis&#44; the rate of abnormal ECG changes suggestive of cardiovascular abnormalities decreased with the use of more restrictive criteria&#46; Independently of the criteria used &#40;SC or RC&#41;&#44; ECG abnormalities were more common among athletes involved in sports characterized by a high dynamic and&#47;or static component&#44; mainly elite athletes competing at national or international level&#46; Otherwise&#44; there was no significant association between the number of hours of training&#47;week and abnormal ECG changes&#46; Abnormal structural changes identified by transthoracic echocardiography were more common in athletes with concomitant abnormal changes on the ECG&#44; as well as in those involved in high-intensity sports and at the national&#47;international level&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The rate of abnormal ECGs was lower than has previously been reported &#40;10-14&#37;&#41;&#44; which is related to the use of more restrictive criteria &#40;the SC and particularly the RC&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;8&#44;16&#44;18&#8211;20</span></a> In a recent study&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> use of the SC compared to the European Society of Cardiology &#40;ESC&#41; recommendations<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a> significantly reduced the rate of false-positive ECG screening results&#44; while still identifying athletes with cardiac conditions&#46; The RC<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> showed an additional improvement compared to the SC&#44; with a significant decrease in false positives in both black and white athletes&#44; without compromising the sensitivity of the ECG in detecting pathological conditions&#46; In fact&#44; some ECG findings&#44; including isolated axis deviation and atrial enlargement&#44; which account for a large number of changes in athletes&#8217; ECGs&#44; do not predict structural cardiac disease when assessed by transthoracic echocardiography&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a></p><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Intensity and type of sport</span><p id="par0120" class="elsevierStylePara elsevierViewall">Few studies have reported the association of type of sport with ECG findings in athletes&#44; and these were mainly performed before the publication of guidelines for ECG interpretation in athletes&#44; in which the sporting disciplines were analyzed individually and not according to the intensity of the dynamic and static components of exercise&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">20&#44;21</span></a> A higher prevalence of ECG changes in athletes has been mainly reported in endurance disciplines&#46; Pelliccia et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> in 1005 athletes performing at national or international level in 38 different sporting disciplines&#44; showed that abnormal ECG changes were more common in endurance sports such as cycling&#44; canoeing&#47;rowing and cross-country skiing&#46; Athletes engaged in endurance sports exhibit more pronounced physiological structural remodeling&#44; which may also manifest with marked ECG alterations&#46; The present study revealed that this relationship between intensity of sport and ECG changes is also evident for non-physiological changes&#46; However&#44; these results should be interpreted with caution&#46; Despite the differences in cardiac loading conditions induced by different types of exercise&#44; some ECG abnormalities are found in athletes engaged in predominantly dynamic as well as in those in predominantly static sports&#46; Although the association is more evident in sports with high dynamic levels&#44; sporting disciplines in this study are typically characterized by a combination of both types of exercise &#40;at least one type with moderate intensity&#41;&#44; as in rugby&#44; swimming and basketball&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Competitive level</span><p id="par0125" class="elsevierStylePara elsevierViewall">The impact of competitive level on electrical remodeling is also not well established and has not been considered in previous classifications of sports&#46; The majority of previous studies were performed in athletes with similar levels of competition&#44; mostly at national or international level&#46; Nonetheless&#44; given the large number of individuals involved in regular sports training at low levels of competition &#40;club or regional&#41; or even not competing&#44; it is important to analyze cardiovascular adaptations in a broad spectrum of competitive levels as well as the other factors that play a part&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a> Although this idea is controversial&#44; it has been proposed that the emotional stress of competition can induce sympathetic activation&#44; which is a potential trigger for arrhythmias or myocardial ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> It might be assumed that sports played at higher levels of competition &#40;national or international&#41;&#44; independently of the intensity of physical exercise&#44; would be associated with greater psychological stress&#46; Nevertheless&#44; no relation between emotional stress induced by highly competitive sport and ECG abnormalities has been reported&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Training volume</span><p id="par0130" class="elsevierStylePara elsevierViewall">Although there is an empirical assumption that the cause-effect relationship between the volume of training and electrical remodeling is obvious&#44; there is little evidence of abnormal ECG findings and the idea is controversial&#46; In a study by Papadakis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> in adolescent Caucasian athletes&#44; the duration of training was not an independent predictor for T-wave inversion in the precordial leads&#44; one of the most frequent abnormalities seen in the ECGs of competitive athletes&#46; Comparing athletes training for fewer hours a week with those training more&#44; the latter more frequently have ECG changes&#44; as shown by Gati et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> with respect to left axis deviation and left atrial enlargement&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Our results offer new insights regarding the association of intensity and level of competition with the presence of abnormal ECG findings&#44; and highlight characteristics that should be considered together when interpreting an athlete&#39;s ECG&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Limitations</span><p id="par0140" class="elsevierStylePara elsevierViewall">The present study has some limitations that should be highlighted&#46; The analysis was retrospective&#46; Some of the characteristics&#44; such as the volume of training&#44; were self-reported by the athletes&#46; Although this was a large cohort compared to previous studies&#44; larger populations should be analyzed&#44; bearing in mind the low rate of the endpoints studied&#46; The low representation of some groups&#44; such as females and non-Caucasians&#44; limits the generalization of these results&#46; Athletes at the extreme end of the spectrum &#40;those with the highest sporting intensity and competitive level&#41; may be more prone to develop abnormal ECG changes&#46; For those with intermediate levels of intensity and competition&#44; correlation with the presence of abnormal ECG findings is difficult to establish due to the dichotomized criteria used in this study&#46; The categorization of sports into nine groups&#44; as in the classification of Mitchell et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> makes this less easy to implement and further subdividing sports may hinder reliable comparisons between the different categories&#46; Although this was not the aim of the study&#44; it is difficult to establish associations between echocardiographic abnormalities and ECG findings&#59; transthoracic echocardiography was not systematically performed and the main purpose of the study was research&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">The present study shows a positive correlation between greater intensity of sport and increased prevalence of ECG abnormalities&#46; This relationship persists with the use of more restrictive criteria for ECG interpretation &#40;the &#8216;Refined Criteria&#8217;&#41;&#44; although the number of abnormal ECGs is lower&#46; The characteristics of specific sports should be taken into account when evaluating elite athletes&#44; to help with early identification of those who may be more prone to develop ECG abnormalities and to prevent unnecessary subsequent evaluation and unwarranted disqualification from competitive sport&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Ethical disclosures</span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Protection of human and animal subjects</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Confidentiality of data</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Right to privacy and informed consent</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "12-lead electrocardiogram"
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              "titulo" => "Transthoracic echocardiogram"
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              "titulo" => "Classification of sports"
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              "titulo" => "Baseline characteristics"
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            1 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Electrocardiographic findings"
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              "titulo" => "Transthoracic echocardiography"
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          "titulo" => "Discussion"
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              "identificador" => "sec0070"
              "titulo" => "Intensity and type of sport"
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              "titulo" => "Competitive level"
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              "titulo" => "Training volume"
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              "titulo" => "Confidentiality of data"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2016-02-03"
    "fechaAceptado" => "2016-04-04"
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          "clase" => "keyword"
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            0 => "Electrocardiogram"
            1 => "Athletes"
            2 => "Type of sport"
            3 => "Competitive level"
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          "palabras" => array:4 [
            0 => "Eletrocardiograma"
            1 => "Atletas"
            2 => "Tipo de desporto"
            3 => "N&#237;vel competitivo"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Athletes can exhibit abnormal electrocardiogram &#40;ECG&#41; phenotypes that require further evaluation prior to competition&#46; These are apparently more prevalent in high-intensity endurance sports&#46; The purpose of this study was to assess the association between ECG findings in athletes and intensity of sport and level of competition&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A cohort of 3423 competitive athletes had their ECGs assessed according to the Seattle criteria &#40;SC&#41;&#46; The presence of abnormal ECGs was correlated with&#58; &#40;1&#41; intensity of sport &#40;low&#47;moderate vs&#46; at least one high static or dynamic component&#41;&#59; &#40;2&#41; competitive level &#40;regional vs&#46; national&#47;international&#41;&#59; &#40;3&#41; training volume &#40;&#8804;20 vs&#46; &#62;20 hours&#47;week&#41;&#59; &#40;4&#41; type of sport &#40;high dynamic vs&#46; high static component&#41;&#46; The same endpoints were studied according to the &#8216;Refined Criteria&#8217; &#40;RC&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Abnormal ECGs according to the SC were present in 225 &#40;6&#46;6&#37;&#41; athletes&#44; more frequently in those involved in high-intensity sports &#40;8&#46;0&#37; vs&#46; 5&#46;4&#37;&#59; p&#61;0&#46;002&#41;&#44; particularly in dynamic sports&#44; and competing at national&#47;international level &#40;7&#46;1&#37; vs&#46; 4&#46;9&#37;&#59; p&#61;0&#46;028&#41;&#46; Training volume was not significantly associated with abnormal ECGs&#46; By multivariate analysis&#44; high-intensity sport &#40;OR 1&#46;55&#44; 1&#46;18-2&#46;03&#59; p&#61;0&#46;002&#41; and national&#47;international level &#40;OR 1&#46;50&#44; 95&#37; CI 1&#46;04-2&#46;14&#59; p&#61;0&#46;027&#41; were independent predictors of abnormal ECGs&#44; and these variables&#44; when combined&#44; doubled the prevalence of this finding&#46; According to the RC&#44; abnormal ECGs decreased to 103 &#40;3&#46;0&#37;&#41;&#44; but were also more frequent in high-intensity sports &#40;4&#46;2&#37; vs&#46; 2&#46;0&#37;&#59; p&#60;0&#46;001&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">There is a positive correlation between higher intensity of sports and increased prevalence of ECG abnormalities&#46; This relationship persists with the use of more restrictive criteria for ECG interpretation&#44; although the number of abnormal ECGs is lower&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
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            "titulo" => "Methods"
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      "pt" => array:3 [
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">O eletrocardiograma &#40;ECG&#41; do atleta pode apresentar altera&#231;&#245;es que requerem avalia&#231;&#245;es adicionais&#44; aparentemente mais frequentes nos desportos de <span class="elsevierStyleItalic">endurance</span>&#46; O objetivo deste trabalho foi avaliar a associa&#231;&#227;o entre a presen&#231;a de altera&#231;&#245;es no ECG do atleta com a intensidade de desporto e n&#237;vel competitivo&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Uma coorte de 3423 atletas de n&#237;vel competitivo realizaram ECG que foi interpretado pelos crit&#233;rios de Seattle &#40;CS&#41;&#46; A presen&#231;a de altera&#231;&#245;es anormais foi correlacionada com&#58; 1&#41; intensidade de desporto &#40;baixo&#47;moderado <span class="elsevierStyleItalic">versus</span> pelo menos um componente elevado&#44; est&#225;tico ou din&#226;mico&#41;&#59; 2&#41; n&#237;vel competitivo &#40;regional <span class="elsevierStyleItalic">versus</span> nacional&#47;internacional&#41;&#59; 3&#41; volume de treino &#40;&#8804;20 <span class="elsevierStyleItalic">versus</span> &#62;20 horas&#47;semana&#41;&#59; 4&#41; tipo de desporto &#40;elevados componentes din&#226;mico <span class="elsevierStyleItalic">versus</span> est&#225;tico&#41;&#46; Os mesmos <span class="elsevierStyleItalic">endpoints</span> foram estudados pelos <span class="elsevierStyleItalic">Refined Criteria</span> &#40;RC&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De acordo com os SC&#44; 225 &#40;6&#44;6&#37;&#41; atletas tinham altera&#231;&#245;es patol&#243;gicas&#44; mais frequentes nos envolvidos em desportos de elevada intensidade &#40;8&#44;0 <span class="elsevierStyleItalic">versus</span> 5&#44;4&#37;&#59; p&#61;0&#44;002&#41;&#44; sobretudo din&#226;mica&#44; e em n&#237;vel nacional&#47;internacional &#40;7&#44;1 <span class="elsevierStyleItalic">versus</span> 4&#44;9&#37;&#59; p&#61;0&#44;028&#41;&#46; O volume de treino n&#227;o esteve significativamente associado a estas altera&#231;&#245;es&#46; Em an&#225;lise multivariada&#44; desporto de elevada intensidade &#40;OR 1&#44;55&#44; IC 95&#37; 1&#44;18-2&#44;03&#59; p&#61;0&#44;002&#41; e o n&#237;vel nacional&#47;internacional &#40;OR 1&#44;50&#44; IC 95&#37; 1&#44;04-2&#44;14&#59; p&#61;0&#44;027&#41; foram preditores independentes de ECG anormais&#44; vari&#225;veis que combinadas duplicaram a preval&#234;ncia&#46; Com os RC o n&#250;mero de ECG patol&#243;gicos decresceu para 103 &#40;3&#44;0&#37;&#41;&#44; tamb&#233;m mais frequentes nos desportos de elevada intensidade &#40;4&#44;2 <span class="elsevierStyleItalic">versus</span> 2&#44;0&#37;&#59; p&#60;0&#44;001&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Verificou-se uma correla&#231;&#227;o positiva entre desporto de elevada intensidade e n&#237;vel competitivo com altera&#231;&#245;es ECG consideradas patol&#243;gicas&#46; Apesar do menor n&#250;mero destas altera&#231;&#245;es&#44; esta rela&#231;&#227;o persiste com o uso de crit&#233;rios mais restritivos na sua interpreta&#231;&#227;o&#46;</p></span>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Left atrial enlargement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76 &#40;2&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Left axis deviation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T-wave inversion &#40;excluding aVR&#44; III and V1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wolff-Parkinson-White pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28 &#40;0&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Right axis deviation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;0&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Long QT interval&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;&#60;0&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ST-segment depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;&#60;0&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Complete left bundle branch block&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;&#60;0&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intraventricular conduction delay &#40;QRS &#62;140 ms&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;&#60;0&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pathological Q waves&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;&#60;0&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Brugada type 2 pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;&#60;0&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">With abnormal SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Without abnormal SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Demographic</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Age &#40;mean &#177; D&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;1&#177;5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;8&#177;5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;1&#177;5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;316&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2468 &#40;72&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">156 &#40;69&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2312 &#40;72&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;338&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Caucasian&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3085 &#40;90&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">197 &#40;87&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2888 &#40;90&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;181&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Black&#47;Caribbean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">177 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;8&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">159 &#40;5&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;047&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Asian&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43 &#40;1&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;467&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other ethnicity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">118 &#40;3&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">112 &#40;3&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;507&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Competitive level and training volume</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>National&#47;international&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2625 &#40;76&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">186 &#40;82&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2439 &#40;76&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;028&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No&#46; hours&#47;week &#40;mean &#177; D&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;2&#177;7&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;0&#177;7&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;7&#177;7&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;734&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;20 hours&#47;week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">714 &#40;20&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48 &#40;21&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">666 &#40;20&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;856&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Intensity of sports &#40;Mitchell classification&#41;</span><a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Class A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">540 &#40;15&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;16&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">504 &#40;15&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;924&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Class B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1566 &#40;45&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75 &#40;33&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1491 &#40;46&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Class C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1317 &#40;38&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">114 &#40;50&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1203 &#40;37&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Class I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">933 &#40;27&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67 &#40;29&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">866 &#40;27&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;380&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Class II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1938 &#40;56&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">126 &#40;56&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1813 &#40;56&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;840&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Class III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">552 &#40;16&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;14&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">520 &#40;16&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;422&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High intensity &#40;at least one of III&#47;C&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1584 &#40;46&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">126 &#40;56&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1458 &#40;45&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Greater dynamic intensity &#40;C-I&#47;II&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1033 &#40;30&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94 &#40;41&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">939 &#40;29&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Greater static intensity &#40;III-A&#47;B&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">267 &#40;7&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;5&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">255 &#40;8&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;153&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Black&#47;Caribbean ethnicity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;95-2&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;078&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">National&#47;international level&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;027&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High-intensity sports&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;18-2&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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