Normal ECG Findings Research Articles

Fine Tuning ECG Interpretation for Young Athletes: ECG Screening Using Z-score-based Analysis

BackgroundElectrocardiograms (ECGs) in athletes commonly reveal findings related to physiologic adaptations to exercise, that may be difficult to discern from true underlying cardiovascular abnormalities. North American and European societies have published consensus statements for normal, borderline, and abnormal ECG findings for athletes, but these criteria are not based on established correlation with disease states. Additionally, data comparing ECG findings in athletes to non-athlete control subjects are lacking. Our objective was to compare the ECGs of collegiate athletes and non-athlete controls using Z-scores for digital ECG variables to better identify significant differences between the groups and to evaluate the ECG variables in athletes falling outside the normal range.MethodsValues for 102 digital ECG variables on 7206 subjects aged 17–22 years, including 672 athletes, from Hawaii Pacific Health, University of Hawaii, and Rady Children’s Hospital San Diego were obtained through retrospective review. Age and sex-specific Z-scores for ECG variables were derived from normal subjects and used to assess the range of values for specific ECG variables in young athletes. Athletes with abnormal ECGs were referred to cardiology consultation and/or echocardiogram.ResultsAthletes had slower heart rate, longer PR interval, more rightward QRS axis, longer QRS duration but shorter QTc duration, larger amplitude and area of T waves, prevalent R’ waves in V1, and higher values of variables traditionally associated with left ventricular hypertrophy (LVH): amplitudes of S waves (leads V1-V2), Q waves (V6, III) and R waves (II, V5, V6). Z-scores of these ECG variables in 558 (83%) of the athletes fell within − 2.5 and 2.5 range derived from the normal population dataset, and 60 (8.9%) athletes had a Z-score outside the − 3 to 3 range. While 191 (28.4%) athletes met traditional voltage criteria for diagnosis of LVH on ECG, only 53 athletes (7.9%) had Z-scores outside the range of -2.5 to 2.5 for both S amplitude in leads V1-V2 and R amplitude in leads V5-6. Only one athlete was diagnosed with hypertrophic cardiomyopathy with a Z-score of R wave in V6 of 2.34 and T wave in V6 of -5.94.ConclusionThe use of Z-scores derived from a normal population may provide more precise screening to define cardiac abnormalities in young athletes and reduce unnecessary secondary testing, restrictions and concern.

Arrhythmias and laboratory abnormalities after an electrical accident: a single-center, retrospective study of 333 cases.

Even though electrical injuries are common in the emergency room, guidelines, consensus, and general recommendations for the management of these patients do not exist in Europe. Documented cases of delayed arrhythmias are rare and their connection with electrical injury has not been fully confirmed. We also use cardio-specific markers for the risk stratification of myocardial injury, but there is no significant study referring to their utility in this clinical situation. These reasons led us to retrospectively analyze all cases of electrical injuries over 23years to determine the prevalence of cardiac arrhythmias (mainly malignant arrhythmias and delayed arrhythmias). We retrospectively searched all patients admitted to the University Hospital in Pilsen, CZ, with a diagnosis of electric injury (ICD diagnostic code T754) from 1997 to 2020. The hospital´s information system was used to research the injury; data were drawn from patient medical records. We identified 333 cases of electrical injury in our hospital. Men accounted for about two-thirds, and women one-third. Children accounted for about one-third of cases. Most were low-voltage injuries (< 1000V, 91.6%). All participants had an initial ECG, and 77.5% of patients had continuous ECG monitoring, usually lasting 24h. Cardiac arrhythmias were noticed in 39 patients (11.7%). The most frequent arrhythmias were: ventricular fibrillation, sinus tachycardia, bradycardia and arrhythmia, atrial fibrillation, and supraventricular tachycardia. The ECG showed cardiac conduction abnormalities in 28 patients (8.1%), and ten patients (3%) had supraventricular or ventricular extrasystoles. In ten cases (3%), we found changes in ST segments and T waves on the initial ECG. Thirty-one patients (9.3%) suffered a loss of consciousness and 50 patients (15.02%) reported paresthesia. The most frequent ion disbalances were hypokalemia (18%) and hypocalcemia (3.3%). Patients with an ion disbalance had significantly more arrhythmias and newly diagnosed cardiac conduction abnormalities. Troponin levels (cTnI or hs-cTnT) were measured in 258 cases (77.48%) and found to be elevated above the 99th percentile in 19 cases (5.7%). Almost one-third of patients had burns of various degrees of seriousness, and 41 patients (12.3%) had concomitant traumatic injuries. Eleven patients underwent pre-hospital resuscitation, three died in the hospital, and another died as result of intracranial hemorrhage. All malignant arrhythmias occurred immediately after the electrical injury, delayed life-threatening arrhythmias were not observed, and no predictive factors of malignant arrhythmias were found. While elevations of cardiac troponins were observed sporadically, they did not appear helpful for risk stratification. In patients with arrhythmias, ion disbalance may be more critical. We concluded that asymptomatic, uninjured adult and pediatric patients with normal initial ECG findings do not need continuous ECG monitoring and may be discharged home. Recommendations for high-risk patients and patients with mild ECG abnormalities at admission are less obvious.

Rhythm and conduction complications after COVID-19 infection in physiological hypertrophy of myocardium (athlete&#39;s heart).

The term 'athletic heart syndrome' (AHS) is used to describe specific circulatory and morphological changes in individuals who participate in sports competitions. The syndrome is characterized by normal cardiac function and reversible myocardial remodelling.The incidence and severity of the post-COVID-19 cardiac pathology in active athletes are so far unclear. One of the complications involving the heart is myocarditis. We present a case of a 23-year-old rower after having a moderate COVID-19 infection. Electrocardiograms showed evidence of a shift in conduction and rhythm disturbances ranging from Group 1 (normal ECG findings) to Group 2 (abnormal ECG findings) on the background of an AHS. Echocardiography (with new methods of evaluating deformity - Global Longitudinal Strain) revealed an area with mildly reduced left ventricular deformity around the apex. To assess the subtle alterations in the myocardium, magnetic resonance imaging was used and focal myocarditis was detected. In our patient, considering the degree of severity of his COVID-19 infection - a moderate one, a decision was taken to perform a clinical and instrumental reassessment of his cardiovascular complications 6 months after the infection.This clinical case presents two substantial issues. First, is the AHS more susceptible to rhythm and conduction disturbances after a COVID-19 infection than that of a person who does not actively participate in sports? Second, what the reversibility or the definitive nature of these disturbances is, and how this impacts the prognosis associated with an active sporting activity.

Cardiac CT evaluation of left atrial diverticulum and accessory appendage

BackgroundThe aim of this study was to evaluate the prevalence, location, size, and morphological features of the left atrial accessory appendage and diverticulum with cardiac computed tomography. Cardiac computed tomography obtained consecutively from 1415 patients with normal ECG findings during a 2-year period were analyzed. Left atrial appendage and diverticulum type, location, and size were recorded and analyzed according to age and gender.ResultsCardiac computed tomography of 1415 (796 males and 619 females) participants aged 44.1 + 12.2 years old were re-evaluated, and 238 atrial diverticulum were found in 234 (16.5%) patients, accessory appendage in 93 (6.5%), and atrial diverticula and accessory appendage together in eight (0.56%) patients. The atrial diverticulum was most frequently observed in the anterosuperior localization (n = 157, 49.2%). One hundred and twenty-three (52%) of the atrial diverticulum were cystic, and 107 (45%) were tubular form. Accessory appendage was observed most frequently in the anterior superior location (n = 65, 20.4%).ConclusionsThe frequency of left atrial diverticulum was found to be 16%, and the frequency of accessory appendage was 6%, consistent with the majority of the literature. Left atrial diverticulum and accessory appendage were detected more frequently in men than in women. Cystic form is more common in left atrial diverticulum.

Diagnosis and demonstration of single coronary artery by multidetector CT angiography: series of two cases

BackgroundSingle coronary artery (SCA) is a rare anomaly, usually diagnosed incidentally during coronary artery angiogram. Individuals with this anomaly mostly remain asymptomatic while some present with symptoms such as chest pain, dyspnoea and even sudden death. The origin and the proximal course of anomalous coronary artery are the main prognostic factors. Several classification systems have been proposed based on the site of origin and anatomical distribution of anomalous artery. Coronary computed tomography angiography has become the reference method for such an assessment noninvasively. Herein, we report a series of two cases of SCA diagnosed on CT angiography. In one case it was single left coronary artery associated with other congenital cardiac anomalies, whereas in other it was single right coronary artery and was an isolated anomaly.Case presentationOur first case was of a 19-year-old female who presented with chest pain and dyspnoea. Transthoracic Echocardiography (TTE) features were suggestive of Tetralogy of Fallot (TOF) with infective endocarditis. Cardiac CT angiography revealed the presence of a large SCA arising from left aortic sinus with absence of normal origin of right coronary artery (RCA). This artery was dividing into and supplying different coronary arterial territories with pre-pulmonic course of RCA. The patient underwent Aortic valve replacement with pulmonary Commissurotomy and improved in post-operative period. Our second case was of a 50-year-old man with complaints of breathlessness and normal ECG and Echocardiography examination findings. Coronary CT angiography revealed the presence of SCA arising from right aortic sinus and supplying the territories of both RCA and Left coronary artery (LCA). The patient was managed conservatively with emphasis on aggressive control of risk factors.ConclusionsSCA is a rare anomaly and may lead to catastrophic life threatening complications. The accurate delineation of the origin and course of the anomalous vessel is of paramount importance while planning surgical intervention. Management usually involves a multi-disciplinary approach with cardiologists and cardiac surgeons aiming for deciding an individual plan based on presentation and anatomy of each case.

Prognostic associations of ECG tracings in hospitalised patients with COVID-19: a systematic review and meta-analysis protocol

IntroductionCOVID-19 is a global pandemic caused by the SARS-CoV-2 virus. Although most COVID-19 cases are asymptomatic or mild, a significant number of patients experienced adverse outcomes. In addition, studies have...

Assessment of electrophysiological changes in the heart by analysing resting electrocardiografic recording and comparison with Seattle criteria in trained male 14-19 years aged volleyball players

Background: Cardiovascular arrest among athletes is prevalent in today's competitive world. As a result, a thorough and routine assessment is advised. The Seattle Criteria are one of the most widely accepted standards in the electrophysiological diagnosis and can reveal possible aberrant findings based on ECG values. Aim of the study: This study aims to investigate the heart's electrophysiological adaptations in trained male volleyball players. This comparison study used the Seattle Criteria to evaluate whether training has a beneficial or negative impact on the heart. Material and methods: In this study, 41 trained male volleyball players aged 14 to 19 were divided into three groups (14–15, 16–17, and 18–19). Each player's resting ECG was recorded and compared to the Seattle criteria. The Kruskal-Wallis nonparametric ANOVA was used, followed by the Mann-Whitney U test for significant outcomes. Results: The Q-T interval differed significantly between the three groups (p &lt; 0.05). In Groups 2 and 3, ST depression was identified using ECG 23% and 8% of the time, respectively. In Groups 1, 2, and 3, ST elevation was detected in 60%, 62%, and 83% of ECGs, respectively. Group 1 had much longer ventricular depolarization and repolarization times. Sinus bradycardia, sinus arrhythmia, and early repolarization (ST elevation) are considered normal ECG findings in athletes, while a ST-segment depression (0.5 mm) is abnormal. Conclusions: It can be inferred that the adaptive aspects of the electrophysiological alterations in the heart as a result of training may help justify the effective workload and prevent cardiac failure in athletes.

PB2306: RELAPSE OF IMMUNE THROMBOCYTOPENIA AND MYOCARDITIS

Background: Immune thrombocytopenia (ITP) is an acquired thrombocytopenia caused by autoantibodies against platelet antigens. ITP most often occurs within a few weeks following a viral infection, but it is also associated with other infections, drugs, hematopoietic malignancies and autoimmune diseases. Myocarditis is an inflammatory disease of cardiac muscle caused by a variety of infectious and noninfectious conditions. Autoimmune mechanisms have been implicated in the pathogenesis of myocarditis with or without a virus trigger. Aims: Our aim is to present an unusual case of myocarditis in a 17-year-old male, with a history of ITP presenting simultaneous relapse of ITP. Methods: A 17-year-old male with a history of ITP presented at the Emergency Department complaining of gingival bleeding, left shoulder pain and fever. Clinical examination showed extremity petechiaes and tachycardia, there was an ST elevation in V2-V6 leads on ECG and laboratory data included PLTs 2000/μL and elevated high sensitivity troponin (1.240pg/mL). He was treated immediately as a relapse of ITP with corticosteroids and he received b-blockers due to persistent tachycardia. Viral and immunological tests were negative. Results: Gradually, during hospitalization, there was an elevation of PLT count and a decrease in serum troponin levels with improving and finally normal ECG findings. The patient was discharged and continued treatment with prednisolone and b-blocker. He was reassessed after one month and troponin levels, PLT counts and ECG were normal. However, the cardiac Magnetic Resonance Imaging (MRI) revealed fibrosis with signal intensity and gadolium enhancement in the anterolateral and inferior segments. After three months a follow up cardiac MRI showed reduction of fibronitic tissue size. Summary/Conclusion: Autoimmunity plays a major role in the pathogenesis of both ITP and myocarditis. It seems that they share common autoimmune pathways and further research of which is important for understanding pathophysiology behind these clinical entities and improving their treatment.

Chest pain post anti-Covid-19 vaccination with mRNA BNT162b2 vaccine : the experience of a secondary hospital

Abstract Funding Acknowledgements Type of funding sources: None. Background Vaccination against Covid-19 has been proved an effective protective measure against the pandemic. It has been noticed that a number of patients visited the emergency department (ED) complaining of chest pain following their vaccination. Purpose To record the patients that visited the ED of our hospital referring chest pain following their vaccination with BNT162b2 vaccine, the clinical and laboratory parameters as well as their final diagnosis. Methods We recorded the patients that visited the ED of our hospital (secondary hospital) referring "chest pain after the vaccine", for a period of 6 months. We included patients that had received the first or the second dose of the vaccine 1-30 days prior their visit. We recorded basic demographic characteristics, ECG findings the laboratory test results as well as the possible diagnosis made in the ED. Results 207 patients visited the ED complaining of "chest pain after having the Covid-19 vaccine", 96 male and 111 female, with mean age 47±8.2 years. 7 patients(3.38%) had elevated high sensitivity troponin and were diagnosed with myocarditis ( 2 female patients aged 5 and 62 years and 5 males aged 18-24 years. In 5/7 ST elevations were recorded in the 12-lead ECG, in 4/7 the transthoracic echocardiogram(TTE) revealed mildly impaired left ventricular function. Myocarditis was confirmed via cardiac MRI in all patients. Virology tests were negative for the common viruses.6/7 visited the ED 2-5 days after the second dose, whereas 1/7 10 days after the first dose). 2 patients(0.96%) were diagnosed with pericarditis (Both of them had received the second dose 5-7 days prior their visit, presented with pericardial rub and diffuse ST elevations in the ECG, as well as elevated CRP and moderate pericardial effusion). For the remaining 198 patients (95.65%) we did not record any abnormal findings in the ECG or the chest X ray and the chest pain was regarded non cardiac. Interestingly enough, 107 patients (51.69%) found to have a mild to moderate increase in the D-Dimer levels (mean 1.1±0.6 mg/l).Pulmonary embolism and aortic dissection was excluded to all of them based on our hospital’s protocol. Conclusion The vast majority (95.65%) of patients complaining of post Covid-19 vaccine chest pain had normal ECG and laboratory findings, suggesting a non cardiac origin.There were diagnosed some cases with myocarditis or pericarditis, a well described possible side effect of the BNT162b2 vaccine. Moreover, 51.69% of these patients were found to have elevated D-Dimer levels but we did not record any clinical significance.

Association Between Temporal Changes in Early Repolarization Pattern With Long-Term Cardiovascular Outcome: A Population-Based Cohort Study.

BackgroundThe prognostic value of early repolarization pattern (ERP) remains controversial. We aim to test the hypothesis that temporal changes in ERP are associated with increased risks for sudden cardiac death (SCD) and cardiovascular death.Methods and ResultsA total of 14 679 middle‐aged participants from the prospective, population‐based cohort were included in this analysis, with ERP status recorded at baseline and during 3 follow‐up visits in the ARIC (Atherosclerosis Risk in Communities) study. We related baseline ERP, time‐varying ERP, and temporal changes in ERP to cardiovascular outcomes. Cox models were used to estimate the hazard ratios (HRs) adjusted for possible confounding factors. With a median follow‐up of 22.5 years, there were 5033 deaths, 1239 cardiovascular deaths, and 571 SCDs. Time‐varying ERP was associated with increased risks of SCD (HR, 1.59 [95% CI, 1.25–2.02]), cardiovascular death (HR, 1.70 [95% CI, 1.44–2.00]), and death from any cause (HR, 1.16 [95% CI, 1.05–1.27]). Baseline ERP was also associated with 3 outcomes. Compared with those with consistently normal ECG findings, subjects with new‐onset ERP or consistent ERP experienced increased risks of developing SCD and cardiovascular death. The time‐varying ERP in women, White subjects, and anterior leads and J‐wave amplitudes ≥0.2 mV appeared to indicate poorer cardiovascular outcomes.ConclusionsOur findings suggest that baseline ERP, time‐varying ERP, new‐onset ERP, and consistent ERP were independent predictors of SCD and cardiovascular death in the middle‐aged biracial population. Repeated measurements of the ERP might improve its use as a risk indicator for SCD.

Declining antibody levels to Trypanosoma cruzi correlate with polymerase chain reaction positivity and electrocardiographic changes in a retrospective cohort of untreated Brazilian blood donors.

BackgroundAlthough infection with Trypanosoma cruzi is thought to be lifelong, less than half of those infected develop cardiomyopathy, suggesting greater parasite control or even clearance. Antibody levels appear to correlate with T. cruzi (antigen) load. We test the association between a downwards antibody trajectory, PCR positivity and ECG alterations in untreated individuals with Chagas disease.Methodology/Principal findingsThis is a retrospective cohort of T. cruzi seropositive blood donors. Paired blood samples (index donation and follow-up) were tested using the VITROS Immunodiagnostic Products Anti-T.cruzi (Chagas) assay (Ortho Clinical Diagnostics, Raritan NJ) and PCR performed on the follow-up sample. A 12-lead resting ECG was performed. Significant antibody decline was defined as a reduction of > 1 signal-to-cutoff (S/CO) unit on the VITROS assay. Follow-up S/CO of < 4 was defined as borderline/low. 276 untreated seropositive blood donors were included. The median (IQR) follow-up was 12.7 years (8.5–16.9). 56 (22.1%) subjects had a significant antibody decline and 35 (12.7%) had a low/borderline follow-up result. PCR positivity was lower in the falling (26.8% vs 52.8%, p = 0.001) and low/borderline (17.1% vs 51.9%, p < 0.001) antibody groups, as was the rate of ECG abnormalities. Falling and low/borderline antibody groups were predominantly composed of individuals with negative PCR and normal ECG findings: 64% and 71%, respectively.Conclusions/SignificanceLow and falling antibody levels define a phenotype of possible spontaneous parasite clearance.

Clinical study of cardiovascular involvement in patients with hypothyroidism

Background: Hypothyroidism is usually associated with the involvement of the cardiovascular system in the form of the cardiac abnormalities. The Research data on this has been found to be limited. The dysfunction of the cardiac caused by hypothyroidism is usually reversible. Objective was to study the incidence of cardiac abnormalities in patients with hypothyroidism.Methods: Total 40 confirmed cases of hypothyroid disease were included in the present study. General investigations, ECG, ECHO was done in all the patients to assess for cardiovascular involvement. The data was entered in the Microsoft Excel worksheet and analysed using proportions.Results: One fourth of the patients were found to have the bradycardia. The Delayed ankle jerk was seen in 67.5% of the cases and the next common CNS manifestation was the hoarseness of the voice. 30% of the case had normal ECG findings. 40% of the cases had the bradycardia. 35% of the cases had the low voltage complexes. 32.5% of the cases had the normal ECHO reports. 27.5% of the cases had the pericardial effusion. Same proportion of the cases were found to have the diastolic dysfunction. But most of them had the dysfunction and the severe cases were found to be very few. Only two patients had IVS thickness.Conclusions: Majority of the cases of the hypothyroidism in the present study were found to have the cardiovascular involvement. This points towards the importance of the early diagnosis of hypothyroidism and the prevention of complications like the cardiovascular system and the central nervous system involvement.

Embracing Different Decision-making Styles

Embracing Different Decision-making Styles

MYOTONIC DYSTROPHY: P.22Subclinical myocardial dysfunction in patients with myotonic dystrophy type 1 and type 2 detected by cardiac magnetic resonance

Myotonic dystrophies (DM) represent the most common hereditary multi-systemic muscle diseases in adults characterized by progressive skeletal muscle degeneration, muscle wasting, myotonia, and multi-organ involvement. Cardiac affection is common, and premature death often occurs due to arrhythmic events. We examined whether signs of cardiac involvement in patients without clinically evident cardiac disease can be detected by a comprehensive cardiac magnetic resonance (CMR) approach. Thirty-five DM patients (13 DM type 1 and 22 DM type 2) without cardiac symptoms and normal ECG and echocardiography findings underwent CMR. The control group consisted of 31 healthy subjects. Our CMR protocol allowed for the determination of late gadolinium enhancement (LGE), myocardial edema, T1 relaxation times, T2 relaxation times, extracellular volume (ECV) and myocardial strain. When compared with controls, DM patients showed alterations of left ventricular function as demonstrated by lower systolic longitudinal and circumferential strain values. Visible myocardial fibrosis was prevalent in 28.6% of DM patients. Markers of diffuse myocardial fibrosis were also significantly elevated (T1 relaxation, ECV). Also, T2 relaxation times indicative of edema-like changes were significantly elevated in DM patients. In conclusion, asymptomatic DM patients had a subclinical impairment of myocardial function and elevated markers of myocardial fibrosis and edema when compared to healthy controls. These findings may indicate a high burden of subclinical myocardial disease in our DM patients with normal routine heart checkup results and an unremarkable history of cardiac disease. To summarize, CMR might be a useful tool to improve cardiac monitoring and outcome in DM1 and DM2 patients especially at early disease stages.

DEMOGRAPHIC AND CLINICAL PREDICTORS OF ACUTE CORONARY SYNDROME IN PATIENTS WITH PREHOSPITAL CHEST PAIN AND BENIGN ECG FINDINGS

Early prehospital recognition of acute coronary syndrome (ACS) has been shown to improve patient outcomes. However, if the prehospital ECG is non-diagnostic for ischemia (i.e., no significant ST elevation or depression), emergency providers have no reliable tools for triaging chest pain. We sought to examine the demographic and clinical predictors of ACS in patients with benign ECG findings. This study prospectively enrolled consecutive, non-traumatic, chest pain patients transported by Emergency Medical Services to one of three UPMC-affiliated tertiary care hospitals in Pittsburgh between 2013 and 2014. We abstracted the following clinical data from patient charts: age; sex; chief complaint (i.e., angina-like pain, dyspnea, palpitation, syncope, gastrointestinal upset, cardiac arrest / pacemaker shock, substance abuse, generalized weakness); past medical history (i.e., hypertension, diabetes, coronary artery disease, prior infarction, and prior coronary revascularization); and presenting vital signs (heart rate, respiratory rate, blood pressure, and oxygen saturation). An independent reviewer examined in-hospital medical records to adjudicate the presence or absence of ACS, defined as the detection of cardiac biomarkers or the presence of ECG, clinical, echocardiographic, or nuclear evidence of acute myocardial injury. Patients with diagnostic ST changes on the prehospital ECG were excluded from the study. We used multivariate logistic regression to identify the predictors of the study outcome. After excluding those with diagnostic ECG (n=87), the final sample included 1,978 patients (age 56±17; 48% females). Overall, 68 patients (3.4%) had ACS with normal or benign ECG findings. In multivariate analysis, age (OR=1.03 [95% CI 1.02-1.05], per 1-year increase), angina-like pain (OR=3.3 [95% CI 1.1-9.7]), palpitation (OR=3.5 [95% CI 1.6-7.8]), and respiratory rate (OR=1.06 [95% CI 1.01-1.11], per 1-unit increase) were the only independent predictors of ACS in this population (all p values < 0.05). Sex, atypical chief complaints, and past medical history were not predictive of the primary outcome. In patients with prehospital chest pain and benign ECG findings, older age, the presence of angina-like pain with palpitation, and elevated respiratory rate are significant predictors of possible ACS. This finding can inform the future education and training of prehospital and emergency providers.

Anew consensus document on electrocardiographic interpretation in athletes: does it help to prevent sudden cardiac death in athletes?

Sudden cardiac arrest or death (SCA/SCD) in athletes has a low event rate. Pre-participation or eligibility screening is a widely accepted method of primary prevention of SCA/SCD in athletes. Most European countries and international sports governing bodies perform ECG-inclusive screening. However, implementation of a resting 12-lead ECG in pre-participation or eligibility cardiac screening is still a topic of debate. Recently, the ‘International recommendations for electrocardiographic interpretation in athletes’ was published in three leading international medical journals. These international ECG criteria are based on studies with detailed information on resting 12-lead ECG of Caucasian and Afro-Caribbean athletes or on consensus in case evidence was lacking. Normal, borderline and abnormal ECG findings in young athletes (age 12–35 years) are clearly described and illustrated to assist the screening physician in interpreting ECGs of athletes correctly.In this ‘point of view paper’ we will discuss whether these new ECG criteria actually help prevent SCA/SCD in athletes.

Training and Experience Matter

A preparticipation evaluation is recommended before engaging in competitive sports, although debate continues whether to include an ECG in addition to a history and physical examination. The limitations of preparticipation screening by history and physical examination alone for the identification of athletes with disorders at risk for sudden cardiac arrest have been recognized by 2 recent consensus statements within the United States.1,2 ECG screening of young athletes is endorsed by several major medical and sporting organizations, such as the European Society of Cardiology (ESC), International Olympic Committee, and Federation Internationale de Football Association, as a means to improve the identification of conditions predisposing to sudden cardiac arrest. However, accurate implementation of an ECG screening program has many challenges and requires a physician infrastructure with adequate sports cardiology resources and training in contemporary athlete-specific ECG interpretation standards. See Article by Dhutia et al In this issue, Dhutia et al3 examined the reproducibility of ECG interpretation using the 2010 ESC, 2013 Seattle Criteria, and 2014 Refined Criteria by 4 experienced and 4 nonexperienced cardiologists in 400 athletes. The study also analyzed the downstream costs of further testing depending on the experience level of the reader. Not surprisingly, the study found that interobserver reliability was better with experienced versus novice readers and improved for both groups with the newer criteria. This was a small sample, and no follow-up was available so it is unknown if any athlete in this cohort had true disease. Physiological changes in the athlete’s heart have made determination of normal ECG findings in the athlete a challenge. The 2010 …

Head-to-head comparison of the diagnostic performance of coronary computed tomography angiography and dobutamine-stress echocardiography in the evaluation of acute chest pain with normal ECG findings and negative troponin tests: A prospective multicenter study

ObjectiveTo perform a head-to-head comparison of coronary CT angiography (CCTA) and dobutamine-stress echocardiography (DSE) in patients presenting recent chest pain when troponin and ECG are negative. MethodsTwo hundred seventeen patients with recent chest pain, normal ECG findings, and negative troponin were prospectively included in this multicenter study and were scheduled for CCTA and DSE. Invasive coronary angiography (ICA), was performed in patients when either DSE or CCTA was considered positive or when both were non-contributive or in case of recurrent chest pain during 6month follow-up. The presence of coronary artery stenosis was defined as a luminal obstruction >50% diameter in any coronary segment at ICA. ResultsICA was performed in 75 (34.6%) patients. Coronary artery stenosis was identified in 37 (17%) patients. For CCTA, the sensitivity was 96.9% (95% CI 83.4–99.9), specificity 48.3% (29.4–67.5), positive likelihood ratio 2.06 (95% CI 1.36–3.11), and negative likelihood ratio 0.07 (95% CI 0.01–0.52). The sensitivity of DSE was 51.6% (95% CI 33.1–69.9), specificity 46.7% (28.3–65.7), positive likelihood ratio 1.03 (95% CI 0.62–1.72), and negative likelihood ratio 1.10 (95% CI 0.63–1.93). The CCTA: DSE ratio of true-positive and false-positive rates was 1.70 (95% CI 1.65–1.75) and 1.00 (95% CI 0.91–1.09), respectively, when non-contributive CCTA and DSE were both considered positive. Only one missed acute coronary syndrome was observed at six months. ConclusionsCCTA has higher diagnostic performance than DSE in the evaluation of patients with recent chest pain, normal ECG findings, and negative troponine to exclude coronary artery disease.

Spasmophilia in the Cardiological Outpatient Department: A Retrospective Study of 228 Sub-saharan Africans over 5 Years

Background: Spasmophilia also called latent tetany is a disorder with a very heterogeneous clinical manifestation which affects particulary young women. Chest pain, constriction of the throat and palpitations are symptoms common to spasmophilia and ischaemic heart disease (IHD). The objective of this work was to assess the incidence and to study the epidemiological, clinical features of spasmophilia in patients with symptoms of ischaemic heart disease. Metods: This was a retrospective study conducted at the cardiology Department of Military Hospital of Ouakam, in Dakar, Senegal, from January 1st 2009 to December 31st 2014). We included all patients who were admitted with manifestation of ischaemic heart disease and who subsequently had a negative evaluation for IHD. We observed the occurrence of neuromuscular hyperexcitability, assessed with Electromyographic (EMG) test. We collected and analyzed epidemiological, clinical, and outcomes data of Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation 228 patients. Results: the incidence of spasmophilia in patient’s reffered with symptoms of ischaemic heart disease was 20% and 100% in patients with normal ECG findings. The mean age of patients was 28.7 ± 18 years with a sex ratio (F/M) of 13.41. The most common presenting symptoms were dominated by chest pain (90%). a history of Insomnia was found in 31 patients (13.60%), and affective disorders were found in 55 patients (24.12%). Biochemical investigation revealed decreased serum magnesium in 5.26%. Medical examinations were normal. All patients were treated with magnesium lactate. 80.6% of patients reported after 3 months complete regression of complaints. 17.2% of patients continued to experience complaints with a significant improvement in terms of reduced frequency and intensity. No complications were noted in our patients after 12 months follow-up. Conclusion: Despite its fearly common occurence, spasmophilia is rarely recognized. We recommend to add EMG test to the algorithm of examinations of patients with chest pain and normal ECG.

Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death

IntroductionThe 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA. MethodsProspective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD2 score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (<72hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year. ResultsWe evaluated 92 patients enrolled over 24 months. Mean age was 68.3±13 years and 61% were male. The mean ABCD2 score was 3 points (≥5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified. ConclusionsIn our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence.