Recommendations for interpretation of 12-lead electrocardiogram in the athlete
TL;DR: The present position paper provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease.
Abstract: Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed.
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TL;DR: The objective of this study was to establish a baseline level of confidence that the once-in-a-lifetime implantation trial—Reduce Inappropriate Therapy protocol can be trusted to provide safe and effective treatment for cardiac arrhythmia and stroke-like episodes.
Abstract: 2D
: two-dimensional
99mTc-DPD
: 99mTechnetium-3,3-diphosphono- 1,2-propanodi-carboxylic acid
ACE
: angiotensin-converting enzyme
AF
: atrial fibrillation
AL
: amyloid light chain
AR
: aortic regurgitation
ARB
: angiotensin receptor blocker
ATTR
: amyloidosis-transthyretin type
AV
: atrioventricular
BiVAD
: biventricular assist device
BNP
: brain natriuretic peptide
BPM
: Beats per minute
CCS
: Canadian Cardiovascular Society
CFC
: cardiofacialcutaneous
CHA2DS2-VASc
: Congestive Heart failure, hypertension, Age ≥75 (doubled), Diabetes, Stroke (doubled), Vascular disease, Age 65–74, and Sex (female)
CMR
: cardiac magnetic resonance
CRT
: cardiac resynchronization therapy
CRT-D
: cardiac resynchronization therapy-defibrillator
CRT-P
: Cardiac resynchronization therapy with a pacemaker
CT
: computed tomography
DC
: direct current
DNA
: deoxyribonucleic acid
E/A
: ratio of mitral peak velocity of early filling (E) to mitral peak velocity of late filling (A)
E/e’
: ratio of early transmitral flow velocity (E) to early mitral annulus velocity (e’)
EACTS
: European Association for Cardio-Thoracic Surgery
ECG
: electrocardiogram
EF
: ejection fraction
EPS
: electrophysiological study
ESC
: European Society of Cardiology
FDA
: (US) Food and Drug Administration
FHL1
: four and a half LIM domains 1
HAS-BLED
: hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly (>65 years), drugs/alcohol concomitantly
HCM
: hypertrophic cardiomyopathy
hs-cTnT
: high sensitivity cardiac troponin T
HTS
: high throughput sequencing
ICD
: implantable cardioverter defibrillator
ILR
: implantable loop recorder
INR
: international normalized ratio
IUD
: intrauterine device
LA
: left atrium
LAMP-2
: lysosome-associated membrane protein 2
LBBB
: left bundle branch block
LEOPARD
: Lentigines, ECG abnormalities, Ocular hypertelorism, Pulmonary stenosis, Abnormal genitalia, Retardation of growth, and sensory-neural Deafness
LGE
: late gadolinium enhancement
LV
: left ventricular
LVAD
: left ventricular assist device
LVH
: left ventricular hypertrophy
LVOTO
: left ventricular outlow tract obstruction
MADIT-RIT
: Multicenter Automatic Defibrillator Implantation Trial—Reduce Inappropriate Therapy
MAPK
: mitogen activated protein kinase
MELAS
: mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes
MERFF
: myoclonic epilepsy with ragged red fibres
MRA
: mineralocorticoid receptor antagonist
MYBPC3
: myosin-binding protein C, cardiac-type
MYH7
: myosin-7 (s-myosin heavy chain)
MYL3
: myosin light chain 3
NOAC
: new oral anticoagulants
NSVT
: non-sustained ventricular tachycardia
NT-proBNP
: N-terminal pro brain natriuretic peptide
NYHA
: New York Heart Association
OAC
: oral anticoagulants
o.d.
: omni die (every day)
PC-CMR
: phase contrast cardiac magnetic resonance
PDE5
: phosphodiesterase type 5
PET
: positron emission tomography
PRKAG2
: gamma-2 sub-unit of the adenosine monophosphate-activated protein kinase
RAAS
: renin angiotensin aldosterone system
RV
: right ventricular
SAM
: systolic anterior motion
SCD
: sudden cardiac death
SAA
: septal alcohol ablation
S-ICD™
: Subcutaneous lead implantable cardioverter defibrillator
SPECT
: single photon emission computed tomography
SSFP
: steady-state free precession
SVT
: supraventricular tachycardia
TOE
: transoesophageal echocardiography
TNNI3
: troponin I, cardiac muscle
TNNT2
: troponin T, cardiac muscle
TPM1
: tropomyosin alpha-1 chain
TTE
: transthoracic echocardiography
TTR
: transthyretin
VF
: ventricular fibrillation
VKA
: vitamin K antagonist
VT
: ventricular tachycardia
WHO
: World Health Organization
Guidelines summarize and evaluate all available evidence at the time of the writing process, on a particular issue with the aim of assisting health professionals in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome, as well as the risk-benefit-ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help the health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.
A great number of Guidelines have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organisations. Because of the impact on clinical practice, quality criteria for the development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines can be found on the ESC website (http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx). ESC Guidelines represent the official position of the ESC on a given topic and are regularly updated.
Members of this Task Force were selected by the ESC to represent professionals involved with the medical care of patients with this pathology. Selected experts in the field undertook a comprehensive review of the published evidence for management (including diagnosis, treatment, prevention and rehabilitation) of a given condition according to ESC Committee for Practice Guidelines (CPG) policy. A critical evaluation of diagnostic and therapeutic procedures was performed including assessment of the risk-benefit-ratio. Estimates of expected health outcomes for larger populations were included, where data exist. The level of evidence and the strength of recommendation of particular management options were weighed and graded according to predefined scales, as outlined in Tables 1 and 2 .
The experts of …
3,276 citations
TL;DR: The role of CMR imaging in the diagnostic work-up of ARVC is analyzed, finding that the lack of specific diagnostic criteria contributes to the under-recognition of the nonclassic variants of AR VC, i.e., dominant or isolated left ventricular disease.
Abstract: Arrhythmogenic right ventricular cardiomyopathy is a rare inherited heart-muscle disease that is a cause of sudden death in young people and athletes. Causative mutations in genes encoding desmosomal proteins have been identifi ed and the disease is nowadays regarded as a genetically determined myocardial dystrophy. The left ventricle is so frequently involved as to support the adoption of the broad term arrhythmogenic cardiomyopathy. Clinical diagnosis can be achieved by demonstrating function and structure changes of the right ventricle, electrocardiogram depolarisation and repolarisation abnormalities, ventricular arrhythmias, and fi brofatty replacement through endomyocardial biopsy. Although specifi c, the standardised diagnostic criteria lack sensitivity for early disease and their primary application remains in establishing the diagnosis in probands. However, the main clinical targets are early detection of concealed forms and risk stratifi cation for preventive strategies, which include physical exercise restriction, antiarrhythmic drugs, and implantable cardioverter-defi brillator therapy. Cascade genetic screening of family members of gene-positive probands allows the identifi cation of asymptomatic carriers who would require lifelong follow-up due to the age-related penetrance.
449 citations
University of Washington1, Mayo Clinic2, University of Connecticut3, Stanford University4, Harvard University5, Karolinska University Hospital6, University of Padua7, University of California, Los Angeles8, Emory University9, Katholieke Universiteit Leuven10, National Heart Foundation of Australia11, University of Arizona12, Seattle Children's13, University of Zurich14, St George's, University of London15, Children's Hospital of Philadelphia16, Qatar Airways17
TL;DR: In this paper, the authors developed a comprehensive training resource to help physicians distinguish normal ECG alterations in athletes from abnormal ECG findings that require additional evaluation for conditions associated with sudden cardiac death.
Abstract: 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 conditions that may increase the risk for SCD. In most countries, there is a shortage of physician expertise in the interpretation of an athlete’s ECG. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from abnormal findings suggestive of pathology. On 13–14 February 2012, an international group of experts in sports cardiology and sports medicine convened in Seattle, Washington, to define contemporary standards for ECG interpretation in athletes. The objective of the meeting was to develop a comprehensive training resource to help physicians distinguish normal ECG alterations in athletes from abnormal ECG findings that require additional evaluation for conditions associated with SCD.
416 citations
St George's, University of London1, University of Washington2, Harvard University3, The Heart Research Institute4, Mayo Clinic5, Sahlgrenska University Hospital6, University of South Carolina7, University of North Carolina at Chapel Hill8, Indiana University9, Stanford University10, University of Hasselt11, Georgia Southern University12, University of California, San Francisco13, Baylor College of Medicine14, Cleveland Clinic15, Thomas Jefferson University16, University of Pennsylvania17, University of Padua18
TL;DR: This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.
373 citations
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References
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TL;DR: This Scientific Statement for health professionals summarizes the evidence for the benefits of physical activity in the prevention and treatment of cardiovascular disease, provides suggestions to healthcare professionals for implementing physical activity programs for their patients, and identifies areas for future investigation.
Abstract: This statement was reviewed by and has received the endorsement of the American College of Sports Medicine.
Regular physical activity using large muscle groups, such as walking, running, or swimming, produces cardiovascular adaptations that increase exercise capacity, endurance, and skeletal muscle strength. Habitual physical activity also prevents the development of coronary artery disease (CAD) and reduces symptoms in patients with established cardiovascular disease. There is also evidence that exercise reduces the risk of other chronic diseases, including type 2 diabetes,1 osteoporosis,2 obesity,3 depression,4 and cancer of the breast5 and colon.6 This American Heart Association (AHA) Scientific Statement for health professionals summarizes the evidence for the benefits of physical activity in the prevention and treatment of cardiovascular disease, provides suggestions to healthcare professionals for implementing physical activity programs for their patients, and identifies areas for future investigation. This statement focuses on aerobic physical activity and does not directly evaluate resistance exercises, such as weight lifting, because most of the research linking physical activity and cardiovascular disease has evaluated aerobic activity. Whenever possible, the writing group has cited summary articles or meta-analyses to support conclusions and recommendations. This evidence supports the recommendation from the Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) that individuals should engage in 30 minutes or more of moderate-intensity physical activity on most (preferably all) days of the week.7
Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure beyond resting expenditure. Exercise is a subset of physical activity that is planned, structured, repetitive, and purposeful in the sense that improvement or maintenance of physical fitness is the objective. Physical fitness includes cardiorespiratory fitness, muscle strength, body composition, and flexibility, comprising a set of attributes that people …
2,137 citations
"Recommendations for interpretation ..." refers background in this paper
...Regular sports participation is encouraged by the medical community as part of cardiovascular prevention measures, because it improves fitness and reduces cardiovascular morbidity and mortality worldwide.(1,2) A large proportion of the young population participates in competitive or recreational sports activity....
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TL;DR: The present article introduces the second part of “Recommendations for Standardization and Interpretation of the Electrocardiogram”, a project initiated by the Council on Clinical Cardiology of the American Heart Association and endorsed by the American College of Cardiology.
1,742 citations
TL;DR: The incidence of sudden cardiovascular death in young competitive athletes has substantially declined in the Veneto region of Italy since the introduction of a nationwide systematic screening in 1982.
Abstract: ContextA nationwide systematic preparticipation athletic screening was introduced in Italy in 1982. The impact of such a program on prevention of sudden cardiovascular death in the athlete remains to be determined.ObjectiveTo analyze trends in incidence rates and cardiovascular causes of sudden death in young competitive athletes in relation to preparticipation screening.Design, Setting, and ParticipantsA population-based study of trends in sudden cardiovascular death in athletic and nonathletic populations aged 12 to 35 years in the Veneto region of Italy between 1979 and 2004. A parallel study examined trends in cardiovascular causes of disqualification from competitive sports in 42 386 athletes undergoing preparticipation screening at the Center for Sports Medicine in Padua (22 312 in the early screening period [1982-1992] and 20 074 in the late screening period [1993-2004]).Main Outcome MeasuresIncidence trends of total cardiovascular and cause-specific sudden death in screened athletes and unscreened nonathletes of the same age range over a 26-year period.ResultsDuring the study period, 55 sudden cardiovascular deaths occurred in screened athletes (1.9 deaths/100 000 person-years) and 265 sudden deaths in unscreened nonathletes (0.79 deaths/100 000 person-years). The annual incidence of sudden cardiovascular death in athletes decreased by 89% (from 3.6/100 000 person-years in 1979-1980 to 0.4/100 000 person-years in 2003-2004; P for trend < .001), whereas the incidence of sudden death among the unscreened nonathletic population did not change significantly. The mortality decline started after mandatory screening was implemented and persisted to the late screening period. Compared with the prescreening period (1979-1981), the relative risk of sudden cardiovascular death in athletes was 0.56 in the early screening period (95% CI, 0.29-1.15; P = .04) and 0.21 in the late screening period (95% CI, 0.09-0.48; P = .001). Most of the reduced mortality was due to fewer cases of sudden death from cardiomyopathies (from 1.50/100 000 person-years in the prescreening period to 0.15/100 000 person-years in the late screening period; P for trend = .002). During the study period, 879 athletes (2.0%) were disqualified from competition due to cardiovascular causes at the Center for Sports Medicine: 455 (2.0%) in the early screening period and 424 (2.1%) in the late screening period. The proportion of athletes who were disqualified for cardiomyopathies increased from 20 (4.4%) of 455 in the early screening period to 40 (9.4%) of 424 in the late screening period (P = .005).ConclusionsThe incidence of sudden cardiovascular death in young competitive athletes has substantially declined in the Veneto region of Italy since the introduction of a nationwide systematic screening. Mortality reduction was predominantly due to a lower incidence of sudden death from cardiomyopathies that paralleled the increasing identification of athletes with cardiomyopathies at preparticipation screening.
1,356 citations
TL;DR: In this series of young athletes, sudden death was usually due to structural cardiovascular disease, and hypertrophic cardiomyopathy was a frequent cause of sudden death; atherosclerotic coronary heart disease was relatively uncommon.
Abstract: The causes of sudden and unexpected death in 29 highly conditioned, competitive athletes, ages 13–30 years, are summarized. Sudden death occurred during or just after severe exertion on the athletic field in 22 of the 29 athletes. Structural cardiovascular abnormalities were identified at necropsy in 28 of the 29 athletes (97%), and in 22 (76%) were almost certainly the cause of death. The most common cause of death in this series was hypertrophic cardiomyopathy, which was present in 14 athletes. Other cardiovascular abnormalities that occurred in more than one athlete were anomalous origin of the left coronary artery from the right (anterior) sinus of Valsalva, idiopathic concentric left ventricular hypertrophy, coronary heart disease and ruptured aorta. Cardiac disease was suspected during life in only seven of the 29 patients, and in only two of the seven was the correct diagnosis made clinically. Hence, in this series of young athletes, sudden death was usually due to structural cardiovascular disease, and hypertrophic cardiomyopathy was a frequent cause of sudden death; atherosclerotic coronary heart disease was relatively uncommon.
1,282 citations
TL;DR: Among patients with a history of idiopathic ventricular fibrillation, there is an increased prevalence of early repolarization and during a mean (+/-SD) follow-up of 61+/-50 months, defibrillator monitoring showed a higher incidence of recurrent ventricularfibrillation in case subjects with a repolarized abnormality than in those without such an abnormality.
Abstract: Background: Early repolarization is a common electrocardiographic finding that is generally considered to be benign. Its potential to cause cardiac arrhythmias has been hypothesized from experimental studies, but it is not known whether there is a clinical association with sudden cardiac arrest. Methods: We reviewed data from 206 case subjects at 22 centers who were resuscitated after cardiac arrest due to idiopathic ventricular fibrillation and assessed the prevalence of electrocardiographic early repolarization. The latter was defined as an elevation of the QRS-ST junction of at least 0.1 mV from baseline in the inferior or lateral lead, manifested as QRS slurring or notching. The control group comprised 412 subjects without heart disease who were matched for age, sex, race, and level of physical activity. Follow-up data that included the results of monitoring with an implantable defibrillator were obtained for all case subjects. Results: Early repolarization was more frequent in case subjects with idiopathic ventricular fibrillation than in control subjects (31% vs. 5%, P<0.001). Among case subjects, those with early repolarization were more likely to be male and to have a history of syncope or sudden cardiac arrest during sleep than those without early repolarization. In eight subjects, the origin of ectopy that initiated ventricular arrhythmias was mapped to sites concordant with the localization of repolarization abnormalities. During a mean (+/-SD) follow-up of 61+/-50 months, defibrillator monitoring showed a higher incidence of recurrent ventricular fibrillation in case subjects with a repolarization abnormality than in those without such an abnormality (hazard ratio, 2.1; 95% confidence interval, 1.2 to 3.5; P=0.008). Conclusions: Among patients with a history of idiopathic ventricular fibrillation, there is an increased prevalence of early repolarization.
1,276 citations
"Recommendations for interpretation ..." refers background in this paper
...In athletes presenting with syncope or cardiac arrest, which remain unexplained after a detailed clinical work-up aimed to exclude cardiac causes and neuromediated mechanisms, the ECG pattern of early repolarization in inferior and/or lateral leads, particularly when associated with a prominent terminal QRS slurring, should raise the suspect of an underlying idiopathic ventricular fibrillation.(63)...
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...Recently, isolated changes of early repolarization in inferior and/ or lateral leads with terminal QRS slurring has been reported in patients with idiopathic ventricular fibrillation.(63) The study was a retrospective analysis of a selected cohort with episodes of short coupled rapid/polymorphic ventricular tachycardia or ventricular fibrillation leading to syncope or cardiac arrest....
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