ECG Interpretation In Athletes Research Articles

Sports cardiology: A glorious past, a well-defined present, a bright future.

The attention towards sports cardiology has dramatically grown after the introduction of preparticipation screening and the need for specific education on electrocardiogram interpretation in athletes, given the differences between athletes and the general population. The present article stresses the need for specific skills, knowledge, and clinical expertise in sports cardiology, which are essential for appropriately screening competitive athletes to prevent sudden cardiac death and avoid overdiagnosis. However, disqualification from sports competitions may lead to sports inactivity, and athletes may enter a gray zone where little or no information is provided about what they can or cannot do to stay active. However, modern sports cardiology cannot neglect the patient's needs and the importance of the safe practice of regular exercise. In this context, the personalized exercise prescription plays a crucial role in the core curriculum and the clinical activity of professionals involved in sports cardiology programs. Given its specificities, sports cardiology requires a formal education plan for medical school students and all residents. Additional education and practice are required for young colleagues who want to focus their professional lives on sports cardiology. The future directions of emerging modern sports cardiology should not neglect the importance of a scientific community that works together, designing multicenter international outcomes-based research to address the many remaining areas of uncertainty.

The Impact of Ethnicity on Athlete ECG Interpretation: A Systematic Review

Athlete ECG interpretation criteria have been developed and refined from research in athlete populations; however, current guidelines are based on available data primarily from Caucasian and Black athletes. This study aimed to assess the impact of ethnicity on ECG interpretation in athletes. A systematic review was conducted of the MEDLINE, EMBASE, Scopus, SPORTDiscus, and Web of Science databases, for papers that assessed athlete screening ECGs and compared findings on the basis of ethnicity. Fifty-one papers which compared ECGs from various ethnicities were included. Most studies assessed Black athletes against Caucasian athletes and found a greater prevalence of T-wave inversion (TWI) (2.6–22.8% vs. 0–5.0%) and anterior TWI (3.7–14.3% vs. 0.6–2.0%). Black athlete subgroups in Africa had TWI (20–40%) and anterior TWI (4.3–18.7%) at a higher prevalence than other Black athletes. Athletes who were defined as mixed-race, Asian, and Pacific Islander are potentially more like Black athletes than Caucasian athletes. Black ethnicity is known to have an impact on the accurate interpretation of athlete ECGs; however, there is nuance related to origin of both parents. Asian and Pacific Islander origin also may impact athlete ECG interpretation. Further research is required to assist in distinguishing abnormal and normal athlete ECGs in different ethnic populations.

Cardiac screening in police and armed forces: a pilot project

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Most international bodies now recommend cardiac screening for all individuals undertaking high intensity physical activity. The sensitivity and specificity of the ECG in cardiac screening is undisputed. Study Objective Two major national institutions (Police Force and the Armed Forces) have now recognized the importance of having a cardiac screening program. As of 2020, the department of Cardiology has been offering remote ECG interpretation for all new recruits. The aim of the study was to retrospectively review this service, specifically looking at the diagnostic yield. Methodology All reported ECGs were retrospectively evaluated. ECG changes were labelled as training related, borderline or pathological ECG patterns as depicted in the 2017 International Recommendations for ECG interpretation in athletes. Demographic, symptom and ECG data were tabulated. The clinical outcomes of those referred were also recorded. Categorical data was presented as percentages. Statistical analysis was performed using SPSS v23. Results 318 recruits were screened, mean age 31.42 ± 13.2 years. The majority (n=196, 61.6%) were younger than 35 years. It was a predominant male population (n=262, 82.4%), all being Caucasian. Armed forces and police force recruits were equally represented (n=154, 48.4% vs n=164, 51.6%). No one reported symptoms (0.0%). The commonest training related changes included early repolarisation (22.3%), left ventricular hypertrophy (15.4%), sinus bradycardia (14.2%) and partial right bundle branch block (7.5%). Some had pathological ECG patterns (Anterior T Wave Inversion n=6 [1.9%], ST segment depression n=6 [1.9%], pathological Q waves n=5 [1.6%], ventricular ectopics n=3 [0.9%], pre-excitation n=2 [0.6%], inferior T Wave inversion n=1 [0.3%], Short QT n=1 [0.3%]). Most were cleared at the initial assessment (n=292, 91.5%). 26 (8.2%) were referred for further evaluation. 14 (4.4%) needed a repeat ECG. Most (n=6, 23.1%) were cleared after secondary evaluation. Another 4 (15.4%) needed surveillance. 6 (23.1%) had a clinical diagnosis, equating to 1 in 53 individuals screened (1.9% of initial cohort). Two patients were already under the care of a cardiologist (n=1 sinus venosus defect with PAPVD, n=1 ischaemic cardiomyopathy). 4 were newly diagnosed cardiac patients (n=1 HCM, n=2 WPW, n=1 Aortopathy). Age did not have any significant impact on the diagnostic yield (<35 [50%] vs ≥35 [50%] years, p=0.244). Conclusion 8.2% were referred for further evaluation (1 in 12). 1.9% (1 in 53) had a clinical diagnosis. This highlights the importance of an ECG based screening algorithm in close liaison with experts in cardiac screening. A clinical diagnosis in law enforcement and army personnel may have important lifelong career implications.

Competitive Sports, the Coronavirus Disease 2019 Pandemic, and Big Ten Athletics.

Competitive Sports, the Coronavirus Disease 2019 Pandemic, and Big Ten Athletics.

Accuracy of the "International Criteria" for ECG screening in athletes in comparison with previous published criteria: rationale and design of a diagnostic meta-analysis

The impact of the 'International Criteria' for ECG interpretation in athletes has further improved the diagnostic accuracy of the 12-lead ECG use for pre-participation screening (PPS) and these criteria have been evaluated in different populations of athletes and settings proving good results. We aim to perform a comprehensive review of the use of the 'International Criteria' for ECG interpretation in athletes, stemming from a systematic review to diagnostic meta-analysis, limiting our inclusion only to observational studies to determine the diagnostic accuracy of ECG for detecting cardiac anomalies related to sudden cardiac death in athletes. This meta-analysis is expected to include several important studies related to PPS on different populations of athletes comparing different ECG criteria and detail important data on the diagnostic accuracy of ECG in PPS. Furthermore, we intend to highlight the advantage of using ECG in PPS. The present diagnostic meta-analysis results will aid sports medicine physicians and cardiologist in adhering to the most accurate criteria for ECG evaluation in athletes and it may help to solve controversies aroused regarding the excess cost of ECG in PPS related to the amount of false positive cases.

CME ECC 65: The Athlete's ECG

CME ECC 65: The Athlete's ECG Abstract. Regular, intensive training in athletes causes a modulation of the heart due to higher vagal tone and emerging hypertrophy. To assess these changes, which can be seen in an athlete's ECG as well, an international group of experts constituted contemporary standards for ECG interpretation in athletes, the "Seattle Criteria" which are discussed in this article: Athletes often have a physiologic sinus bradycardia with a heart rate between 30 and 60 bpm and a pronounced respiratory arrhythmia. A junctional rhythm with retrograde depolarisation of the atria frequently occurs as well, especially at rest. Early repolarisation is also an occasional phenomenon in athletes. Depending on its morphology and the history of the athlete it may be regarded as physiologic. This article shall help to evaluate an athlete's ECG in a physician's routine.

Electrocardiographic findings in elite professional cyclists: The 2017 international recommendations in practice

ObjectivesTo categorize ECG findings into normal, borderline or abnormal in a team of professional elite cyclists according to the 2017 international recommendations. DesignA cross-sectional study was performed. MethodsTwelve-lead ECGs collected between 2012 and 2015 as part of an annual routine examination for a team of professional elite cyclists were analysed, and findings classified as normal, borderline or abnormal according to the 2017 recommendations. Information on exercise capacity testing was also collected. ResultsA total of 43 professional cyclists, all Caucasian males ranging between 21 and 38years of age, were included. Given most were followed up for multiple years, a total of 103 ECGs were collected. Normal variations were found in 43 (100%) athletes; borderline findings in 4 (9.3%), and 2 (4.7%) athletes had abnormal findings. No pathology was identified on further investigation of the four cyclists with two concurrent borderline or any abnormal ECG findings, reflecting a false positive rate of 9.3%. ConclusionsIn this team of professional cyclists, the prevalence of abnormal ECG findings requiring further investigation, and the false positive rate were low, despite a very high prevalence of normal variations expected in athletes. This may be as a result of heightened specificity of the new international recommendations for ECG interpretation in athletes.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

Inter-Rater Reliability and Downstream Financial Implications of Electrocardiography Screening in Young Athletes.

Preparticipation screening for cardiovascular disease in young athletes with electrocardiography is endorsed by the European Society of Cardiology and several major sporting organizations. One of the concerns of the ECG as a screening test in young athletes relates to the potential for variation in interpretation. We investigated the degree of variation in ECG interpretation in athletes and its financial impact among cardiologists of differing experience. Eight cardiologists (4 with experience in screening athletes) each reported 400 ECGs of consecutively screened young athletes according to the 2010 European Society of Cardiology recommendations, Seattle criteria, and refined criteria. Cohen κ coefficient was used to calculate interobserver reliability. Cardiologists proposed secondary investigations after ECG interpretation, the costs of which were based on the UK National Health Service tariffs. Inexperienced cardiologists were more likely to classify an ECG as abnormal compared with experienced cardiologists (odds ratio, 1.44; 95% confidence interval, 1.03-2.02). Modification of ECG interpretation criteria improved interobserver reliability for categorizing an ECG as abnormal from poor (2010 European Society of Cardiology recommendations; κ=0.15) to moderate (refined criteria; κ=0.41) among inexperienced cardiologists; however, interobserver reliability was moderate for all 3 criteria among experienced cardiologists (κ=0.40-0.53). Inexperienced cardiologists were more likely to refer athletes for further evaluation compared with experienced cardiologists (odds ratio, 4.74; 95% confidence interval, 3.50-6.43) with poorer interobserver reliability (κ=0.22 versus κ=0.47). Interobserver reliability for secondary investigations after ECG interpretation ranged from poor to fair among inexperienced cardiologists (κ=0.15-0.30) and fair to moderate among experienced cardiologists (κ=0.21-0.46). The cost of cardiovascular evaluation per athlete was $175 (95% confidence interval, $142-$228) and $101 (95% confidence interval, $83-$131) for inexperienced and experienced cardiologists, respectively. Interpretation of the ECG in athletes and the resultant cascade of investigations are highly physician dependent even in experienced hands with important downstream financial implications, emphasizing the need for formal training and standardized diagnostic pathways.

81 The Financial Implications of Application of the Refined ECG Criteria in Pre-Participation Screening of Elite Athletes: Abstract 81 Table 1

<h3>Introduction</h3> Sudden cardiac death in young athletes is commonly due to inherited cardiac diseases that can be detected during life. The International Olympic Committee (IOC) and European Society of Cardiology (ESC) recommend pre-participation screening with ECG in young athletes to detect those at risk. The 2010 ESC recommendations and Seattle criteria recommendations were developed to aid the ECG interpretation in athletes given that cardiovascular remodelling in the conditioned athlete is associated with physiological ECG changes. Antagonists of ECG inclusive pre-participation screening have questioned the high rates of false positive ECG’s in athletes despite these recommendations, as well as the cost effectiveness of such practice. The recently published refined criteria for ECG interpretation in athletes have demonstrated a significant reduction in the false positive ECG rate without compromising sensitivity of diagnosis. The aim of this study was to report the financial implications of application of the three ECG interpretation criteria in detecting potentially sinister diseases in young UK athletes. <h3>Methods</h3> Between 2011–2013, 2,493 consecutive asymptomatic and apparently healthy elite athletes aged 14–35 years underwent pre-participation screening with ECG conducted by a cardiologist at a cost of £35 per athlete. ECG interpretation was in line with 2010 ESC recommendations. Athletes with ECG abnormalities warranted further evaluation which would be facilitated in secondary care as recommended by the ESC. The Seattle criteria and refined criteria for ECG interpretation were applied to this cohort retrospectively. <h3>Results</h3> 2,493 athletes (mean age 19.8 ± 4 years, 1934 (78%) male, 2,214 white (88.9%), 72 black (3%), 227 mixed/other (8.1%)) from 23 sporting disciplines were screened. 7 athletes (0.3%) were diagnosed with a potentially sinister cardiac condition by ECG irrespective of the ECG criteria used (4 HCM, 1 LQTS, 2 WPW). The refined criteria would reduce the minimum overall cost per sinister cardiac condition identified from £31,191 to £17,459, equating to a 44% reduction. <h3>Conclusion</h3> The refined criteria for ECG interpretation could reduce the overall cost of pre-participation screening by a minimum by £39 per athlete (Table 1). In the current financial climate, the refined criteria provides a welcome cost saving practice without compromising efficacy of screening. The data is based on heavily subsidised preliminary investigations and modest tariffs of further investigations in the National Health Service (NHS); therefore the refined criteria is likely to have a greater impact in other healthcare models.

Comparison of Electrocardiographic Criteria for the Detection of Cardiac Abnormalities in Elite Black and White Athletes

Recent efforts have focused on improving the specificity of the European Society of Cardiology (ESC) criteria for ECG interpretation in athletes. These criteria are derived predominantly from white athletes (WAs) and do not account for the effect of Afro-Caribbean ethnicity or novel research questioning the relevance of several isolated ECG patterns. We assessed the impact of the ESC criteria, the newly published Seattle criteria, and a group of proposed refined criteria in a large cohort of black athletes (BAs) and WAs. Between 2000 and 2012, 1208 BAs were evaluated with history, examination, 12-lead ECG, and further investigations as appropriate. ECGs were retrospectively analyzed according to the ESC recommendations, Seattle criteria, and proposed refined criteria which exclude several specific ECG patterns when present in isolation. All 3 criteria were also applied to 4297 WAs and 103 young athletes with hypertrophic cardiomyopathy. The ESC recommendations raised suspicion of a cardiac abnormality in 40.4% of BAs and 16.2% of WAs. The Seattle criteria reduced abnormal ECGs to 18.4% in BAs and 7.1% in WAs. The refined criteria further reduced abnormal ECGs to 11.5% in BAs and 5.3% in WAs. All 3 criteria identified 98.1% of athletes with hypertrophic cardiomyopathy. Compared with ESC recommendations, the refined criteria improved specificity from 40.3% to 84.2% in BAs and from 73.8% to 94.1% in WAs without compromising the sensitivity of the ECG in detecting pathology. Refinement of current ECG screening criteria has the potential to significantly reduce the burden of false-positive ECGs in athletes, particularly BAs.

The new Seattle Criteria reduce the prevalence of abnormal ECG findings in professional football players

Purpose: To compare the new "Seattle Criteria" for ECG interpretation in athletes, with former recommendations from ESC. Methods: In 2008, 574 professional football players (mean age 25, range 18-38 years) in Norway underwent preparticipation ECG-screening (CARDIOLINE, RealClick version 3.5.4., Milan, Italy). ECGs were read manually by one investigator, measuring the global QRST complex with calipers. Analyzes were performed according to the definitions of Corrado et al. 2010, as "updated" by Uberoi et al. 2011, and the new "Seattle criteria" by Drezner et al. 2013, and the results were compared. Results: Main differences are presented in Table 1. Altogether 111 (19%) players had abnormal ECG-findings according to the "Seattle Criteria", compared to 292 (51%) applying the former ESC recommendations (p<0.001). Table 1. Main differences in normal and abnormal ECG findings between ESC versus "Seattle criteria" in interpreting athletes' ECG *Except in Africans. NA, not applicable; TWI, T-wave inversion. Conclusions: The significant reduction of 32% abnormal ECG-findings applying the new "Seattle Criteria" versus the ESC's recommendations will probably reduce the need and costs of extended examinations after preparticipation ECG-screening of athletes.

Electrocardiographic interpretation in athletes: the ‘Seattle Criteria’

Sudden cardiac death (SCD) is the leading cause of death in athletes during sport. Whether obtained for screening or diagnostic purposes, an ECG increases the ability to detect underlying cardiovascular...

062 Re-appraisal of ECG interpretation in young athletes: should axis deviation and voltage criterion for atrial enlargement be categorised as abnormal in athletes? The British experience

PurposeThe European Society of Cardiology (ESC) guidelines for ECG interpretation in athletes facilitate the differentiation of physiological changes (Group 1) representing cardiac adaptation from those potentially associated with an increased...

063 Sex and ethnicity specific ECG differences in elite athletes: relevance to pre-participation cardiovascular evaluation: the British experience

PurposeThe athlete's ECG is affected by several demographic factors but there is a paucity of data relating to the impact of the athlete's sex and ethnicity. The ESC guidelines for...

149 Ethnic differences in performance of the 2010 European Society of Cardiology criteria for ECG interpretation in athletes

BackgroundPhysical activity is associated with ECG phenotypes that may overlap with those observed in conditions predisposing to sudden cardiac death. In 2005 the study group of sports cardiology produced guidelines...

Accuracy of ECG interpretation in competitive athletes: the impact of using standardised ECG criteria

BackgroundInterpretation of ECGs in athletes is complicated by physiological changes related to training. The purpose of this study was to determine the accuracy of ECG interpretation in athletes among different...

Performance of the 2010 European Society of Cardiology criteria for ECG interpretation in athletes

BackgroundThe European Society of Cardiology (ESC) recently published revised criteria for ECG interpretation in the athlete.ObjectiveTo examine the performance of the 2010 ESC ECG criteria in a population of athletes...