Review
Interpretation of the Electrocardiogram in Athletes

https://doi.org/10.1016/j.cjca.2015.10.026Get rights and content

Abstract

Regular intensive participation in sport results in electrical and structural alterations within the heart that can manifest on the surface electrocardiogram (ECG). In addition to the actual sporting discipline and the volume and intensity of exercise being performed, other factors play a role in the development of certain ECG patterns including sex, age, and ethnicity. In some instances, large male endurance athletes and those of African or Afro-Caribbean origin (black athletes), might exhibit ECG patterns that overlap with those seen in patients with cardiomyopathy and channelopathies, which are recognized causes of exercise-related sudden cardiac death. The ability to distinguish accurately between benign physiological electrical alterations and pathological ECG changes is crucial to prevent the unnecessary termination of an athlete's career and to minimize the risk of sudden death. Several recommendations currently exist to aid the physician in the interpretation of the athlete's ECG. In this review we discuss which ECG patterns can safely be considered benign as opposed to those that should prompt the physician to consider cardiac pathology.

Résumé

Une participation intensive et régulière à des activités sportives peut entraîner l’apparition de modifications électriques et structurelles du cœur pouvant être décelées par un électrocardiogramme (ECG) de surface. En plus du type de discipline sportive pratiquée et de la quantité et de l’intensité d’exercice effectué, divers facteurs jouent un rôle dans l’apparition de certains tracés d’ECG, notamment le sexe, l’âge et l’origine ethnique. Dans certains cas, les athlètes de sexe masculin et de grande taille qui pratiquent un sport d’endurance et les athlètes d’origine africaine ou afro-caribéenne (de race noire) peuvent présenter des tracés d’ECG semblables à ceux des patients atteints d’une cardiomyopathie ou d’une canalopathie, lesquelles, on le sait, peuvent entraîner une mort subite d’origine cardiaque liée à l’exercice. La capacité de distinguer clairement une modification électrique physiologique bénigne d’une modification pathologique à l’ECG est cruciale pour éviter de mettre inutilement fin à la carrière d’un athlète et de minimiser le risque de mort subite. Il existe actuellement plusieurs recommandations pour aider le médecin à interpréter les tracés d’ECG d’un athlète. Nous vous présentons dans cet ouvrage une revue des tracés d’ECG qui peuvent d’emblée être considérés comme bénins ainsi que de ceux qui doivent amener le médecin à envisager la présence d’une pathologie cardiaque.

Section snippets

Bradyarrhythmia

Sinus bradycardia is seen in up to 80% of athletes,1, 2, 3 however, a heart rate < 35 beats per minute (bpm) is rare and tends to only occur in endurance athletes.4 Sinus arrhythmia is noted in approximately 70% of athletes and first-degree atrioventricular (AV) heart block is present in 5%-13% of athletes.1, 3, 5 Mobitz type 1, junctional rhythm, and sinus pauses are also common (31%, 20%, and 37%, respectively)6 but predominantly at night. With increased sympathetic tone during exercise,

Endurance athletes

Endurance athletes such as those who compete in long-distance running, cycling, swimming, rowing, or canoeing show the highest prevalence of bradyarrhythmia, repolarization changes, and voltage criteria for ventricular hypertrophy. The prevalence of ECG changes is similar in men and women other than a lower prevalence of voltage criteria for LVH and ERPs in women.19

Although TWI in the chest leads (with the exception of V1-V2) is considered abnormal, there are data to suggest that up to 14% of

European Society of Cardiology recommendations

In 2010, the European Society of Cardiology (ESC) published a pragmatic approach to the interpretation of the young athlete's ECG30 on the basis of the findings from an Italian study of 32,652 athletes (mean age, 22.3 years old).31 ECG changes were categorized into benign training-related changes (class 1), or nontraining (possibly pathological) ECG patterns (class 2). The latter were present in < 5% of athletes whereas group 1 changes were detected in up to 80% of athletes (Fig. 5).

Group 1

Abnormal ECG Patterns

Although there is an overlap between some ECG patterns observed in athletes and individuals with cardiomyopathy, certain ECG patterns are definitely regarded as abnormal irrespective of the demographic characteristics or symptomatic status of the athlete (Fig. 8). These include ST segment depression and left bundle branch block. Whereas partial right bundle branch block (RBBB) is regarded as a normal variant, the situation with complete RBBB is less clear. RBBB is considered pathological

Conclusions

The ECG of the athlete usually exhibits changes because of their increased vagal tone and large cardiac dimensions. Certain manifestations of the athlete's ECG might overlap with those observed in cardiac diseases implicated in sudden cardiac death in athletes. An understanding of the physiological spectrum of ECG changes in athletes in relation to age, sex, ethnicity, and type of sport helps reduce the number of false positive results during preparticipation screening of asymptomatic athletes.

Acknowledgements

The authors thank Dr Velislav Batchvarov for assistance in obtaining ECGs.

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