Filling the gap of understanding the athlete’s ECG

Abstract

Prompted by the recommendations of the European Society of Cardiology, International Olympic Committee, Federation International of Football Association and Union Cycliste International, much attention is currently being paid to the ECG in athletes. Conflicting opinions, however, exist regarding the pitfalls of the ECG interpretation and the implementation of ECG-based screening in athletes. In particular, concern exists that routine ECG screening may convey a large number of borderline (and false positive) results, requiring additional testing and substantially increasing the costs. While occurrence of ECG abnormalities unrelated to training, and potential expression of pathologic cardiac conditions, is low (about 5%) in young Caucasian athletes, it may be larger (10 to 20%) in Black athletes, either African-Americans, Afro-Caribbeans or native Africans. The clinical significance of certain ECG abnormalities remains uncertain, such as the isolated R/S-wave voltages criteria for LV hypertrophy (and the indication for imaging testing), the inverted T-waves in anterior precordial leads (often considered a trait peculiar to Blacks), left atrial enlargement and left axis deviation (that are seldom reported in athletes). To fill this gap in our knowledge, a close confrontation among world experts is now ongoing, with the ambition of redefining the criteria for ECG normality in accord with the athlete’s age, ethnic origin and gender. It is plausible that the newly refined criteria for ECG interpretation will help to reduce false-positive results by enhancing disease detection in athletes, smoothing most of the controversies surrounding the interpretation of ECGs and solving the obstacles to a wide implementation of ECG screening in young athletes.In recent years, an increasing interest in the athlete’s ECG was prompted by the recommendations of the scientific societies (European Society of Cardiology, ESC) and sport governing organizations (International Olympic Committee, IOC; Federation International of Football Association, FIFA; Union Cycliste Internationale, UCI) that advocate implementation of the ECG in screening competitive athletes. These recommendations have raised conflicting opinions and fuelled the ongoing scientific debate regarding the screening, mostly focused on the potential pitfalls of ECG in trained athletes. The ESC and IOC statements supported implementation of the screening as a feasible and efficient strategy to prevent athletic field deaths, and suggested that screening best serves to this scope if performed systematically not only with personal and family history and physical examination, but also with the ECG. This proposal largely derives from the long-standing experience in Italy, where a preventive screening programme for competitive athletes has been implemented by legislative initiative since 1982. Other European countries had either limited screening programmes or no medical programmes for competitive athletes, and the endorsement by the ESC and IOC represented a big turning point in the medical care of athletes. This proposal, however, has been opposed at length by the American Heart Association (AHA) panel, which ‘does not believe it to be either prudent or practical to recommend the routine use of test such as 12lead ECG’. Most of the AHA criticism is based on practical considerations, including the lack of adequate economic resources available worldwide, but also the absence of an appropriate class of specialized physicians to interpret the ECG results. In addition, alarm was raised that the widespread use of ECG would convey a number of borderline (and false positive) test results, requiring additional testing to resolve the ambiguity of diagnosis and increasing substantially the cost of the screening. These conflicting opinions have fuelled an intense debate, but no efforts have been made to solve the origin of the conflicting opinions, that is, the ambiguities of the ECG, which not uncommonly shows in athletes a broad spectrum of abnormalities, mimicking those found in patients with structural cardiac disease. Finding an abnormal ECG pattern in a trained