Relation of Race to Electrocardiographic Patterns in Elite American Football Players

Electrocardiographic Findings in Professional Male Athletes

OBJECTIVE

To generate granular normative electrocardiogram (ECG) data and characterize the variation by ethnicity and sport played.

DESIGN

Cross-sectional study; ECGs were collected from preseason screening programs from 2012 to 2019 and interpreted in accordance with athlete-specific guidelines.

SETTING

Of the professional athletes based in Vancouver, the North Shore Heart Centre performs the annual preparticipation ECG screening.

PARTICIPANTS

Seven hundred fifty-three professional male athletes competing in hockey, football, lacrosse, skiing, and snowboarding.

INTERVENTIONS

Independent variables include commonly transcribed electrocardiographic findings, for example, those indicating benign and pathologic findings.

MAIN OUTCOME MEASURES

Prevalence of and variance in electrocardiographic findings by sport played and ethnicity.

RESULTS

Of the 753 athletes, 171 (22.3%) were National Hockey League, 358 (47.5%) were Canadian Football League, 163 (21.6%) were Major League Soccer and/or the Canadian National Soccer team, and 61 (8%) others. The most common finding, sinus bradycardia, was more likely in both soccer (P < 0.001) and hockey (P < 0.001) versus football players. Early repolarization (ER) was more likely in soccer players versus both hockey (P < 0.001) and football players (P = 0.001). Within football, Black athletes (BA) were more likely than White athletes to display ER (P = 0.009), left ventricular hypertrophy (P = 0.004), and nonspecific ST changes (P = 0.027).

CONCLUSION

Our study contributes to the generation of normative data for ECG findings while accounting for ethnic and sport-specific variation. The expected clinical presentation of endurance athletes, including soccer players, and the possible predisposition of BA to develop distinct adaptations can augment clinical care by delineating physiology from pathologic changes.

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.

Utility of Exercise Stress Testing in Pediatric Patients with T-Wave Inversions

T-wave inversions (TWI) in inferolateral electrocardiogram (ECG) leads (II, III, aVF, V5-V6) are often suggestive of cardiac pathology in adult patients. They are a common reason of additional testing in pediatric patients. The goal of the study is to determine correlation of exercise stress test T-wave response with diagnosis of cardiac pathology. This is a retrospective review of pediatric patients < 21 years with the finding of baseline TWI in inferior (II, III, avF) and/or lateral (V5-V6) leads on 12-lead ECG. All patients underwent treadmill exercise stress test (EST) and an echocardiogram within 1 year of each other. Demographics, baseline ECG findings, echocardiogram results, and EST data were recorded. T-wave reversion was considered complete if T waves demonstrated normalization during exercise, partial if there was minimal improvement, and no response if there was no change or worsening of inversions. In our cohort of 72 patients with a mean age 14.6 (± 2.9) years and 61% males, 59 (82%) had a structurally normal heart. Thirteen patients had evidence of structural or functional heart disease. Of the 59 patients, 83% had either complete or partial T-wave response. Among the 13 patients with heart disease, two patients had genetic testing consistent with risk for hypertrophic cardiomyopathy and had complete and partial response on EST. Exercise stress testing for TWI in pediatric patients has low sensitivity and specificity for the diagnosis of cardiac disease and routine use in this patient population may not be indicated.

Electrocardiographic and Echocardiographic Findings in Elite Ghanaian Male Soccer Players

OBJECTIVE

To analyze the athlete's heart of adult and adolescent elite male soccer players by electrocardiography (ECG) and echocardiography (ECHO) and to describe typical ECG and ECHO findings in this cohort (West African elite soccer players).

DESIGN

A cross-sectional study of ECGs and ECHOs conducted as part of precompetition medical assessment for national male soccer teams preparing for various Fédération Internationale de Football Association (FIFA) tournaments in 2016 and 2017.

SETTING

Ghana National Football Association.

PARTICIPANTS

One hundred fifty-nine players playing for the National male soccer teams preparing for tournaments in 2016 and 2017.

INTERVENTIONS

Precompetition medical assessment using ECGs and ECHOs.

MAIN OUTCOME MEASURES

Number of athletes with abnormal ECGs and ECHO findings.

RESULTS

Twenty-three percent of the players had abnormal ECGs. Nine percent of the participants had T-wave inversions in lateral leads (V5-V6). Sokolow-Lyon criteria for left ventricular hypertrophy were present in 64% of participants. Thirty-six (23%) players had left ventricular wall thickness (LVWT) ≥13 mm, with no player exceeding 16 mm. Four percent of players had left ventricular cavity dimension greater than 60 mm. Relative wall thickness >0.42 was present in 44% of the players.

CONCLUSIONS

Uncommon ECG changes seem to be more common in elite Ghanaian soccer players compared with previously reported results for Caucasians and even mixed populations of black athletes. Although ST elevation, T-wave inversions, and LVWT up to 15 mm are common, ST depression, deep T-waves in lateral leads, and LVWT ≥16 mm always warrant further clinical and scientific investigations.

For the Evaluation of Pacific Island Athletes, an ECG and Echocardiography Are Highly Recommended

Physical exercise increases the relative risk of sudden cardiac death (SCD) in athletes when compared to a non-sporting population. Pre-participation evaluation (PPE) of athletes is thus of major importance. For Pacific Island athletes, medical guidelines recommend an echocardiography to complement a PPE including personal and family history, a physical examination and a resting twelve-lead electrocardiogram (ECG). Indeed, silent rheumatoid heart diseases found in up to 7.6% of adolescents give rise to severe valve lesions, which are the main causes of SCD in Pacific Island athletes. This short review examines the incidence rate of SCD in Pacific Island athletes and indicates how a questionnaire, physical examination, ECG and echocardiography can prevent it.

Electrocardiographic and Echocardiographic Findings in Black Athletes: A General Review

BACKGROUND

Participation in regular physical activity produces electrophysiological and structural cardiac changes in electrocardiograms (ECGs) and echocardiographs (ECHOs) of athletes, and the term "athlete's heart" is used to describe these physiological cardiovascular adaptations. Extent and type of sporting discipline, age, sex, body dimensions, and ethnicity have an influence on cardiac remodeling.

OBJECTIVE

As the recent scientific literature increasingly reports on ethnicity-specific ECG and ECHO findings in black athletes, it is the aim of this review to provide an overview of ECG and ECHO findings among athletes of black African/Afro-Caribbean descent.

DATA SOURCES

A systematic search of PubMed and MEDLINE databases up to and including August 2017 was conducted using the following terms/phrases "black OR African OR Afro-Caribbean athlete heart," "black OR African OR Afro-Caribbean athlete electrocardiogram," and "black OR African OR Afro-Caribbean athlete echocardiogram." The search generated a total of 130 papers, out of which 16 original articles fitted our criteria and were selected for this review.

MAIN RESULTS

The various studies reviewed revealed that about 10% to 30% of black African/Afro-Caribbean athletes had abnormal ECG. R/S voltage criteria exceeding hypertrophic indices were found in about 60% to 89% of black African/Afro-Caribbean athletes. ST-segment elevation (17%-90%) and T-wave inversions were also common findings among this ethnicity. About 10% to 12% of black African/Afro-Caribbean athletes had a left ventricular wall thickness ranging from 13 to 15 mm. Cavity dimensions ranged from 40 to 66 mm in black African/Afro-Caribbean athletes with a relative wall thickness >0.44.

CONCLUSIONS

Updated ethnic-specific guidelines are required to discriminate physiological from pathologic hypertrophy and repolarization changes. Future studies should focus on homogeneous cohorts of African athletes.

Electrocardiographic pattern of apparently healthy African adolescent athletes in Nigeria

Background

Strategies to prevent sudden cardiac death (SCD) among young athletes have become topical worldwide and unrecognized cardiac pathology has been identified as a leading cause. Black ethnicity has been reported as an independent predictor of abnormal electrocardiography (ECG) findings among athletes and the frequency and significance of training-related ECG findings versus findings suggestive of an underlying pathology in the young African athletes is crucial.

Methods

This cross sectional study aimed to determine the prevalence and distribution of ECG patterns in young athletes and controls. A total of 360 participants (180 athletes and 180 controls) were recruited from six secondary schools in Lagos, Nigeria between November 2014 and July 2015. Evaluation included interviewer-administered questionnaires for relevant history, physical examination and resting 12 - lead ECG for each participant.

Results

Abnormal ECG patterns were found in 48.3% of athletes and 35.6% of controls. Training-related ECG findings occurred in 33.3% of athletes and 18.3% of controls. Athletes and controls had 7.7% prevalence of training un-related ECG patterns respectively. Left ventricular hypertrophy was the most common ECG finding among the athletes and male athletes had a higher prevalence of ECG abnormalities compared to females.

Conclusion

Adolescent athletes in Nigeria have a high prevalence of training-related ECG patterns and athletes and non-athletes alike have similar proportions of ECG findings suggestive of underlying structural heart disease. Cardiovascular evaluation including ECG should be performed for young athletes prior to competition at any level and should also be considered as part of pre-school entry assessment for all children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02557-8.

[Particularities of African descent patient's electrocardiogram]

Particularities of African descent patient's electrocardiogram have been described for many years. Variations such as higher QRS voltage, early repolarization pattern, precordial T-wave inversion and anterior ST segment elevation associated with T-wave inversion are more frequently observed. Ignorance of these variations can lead to misdiagnosis or therapeutic negligence. We present the electrocardiographic particularities attributed to the patient of African origin.

The Impact of Ethnicity on Cardiac Adaptation

Regular intensive exercise is associated with a plethora of electrical, structural and functional adaptations within the heart to promote a prolonged and sustained increase in cardiac output. Bradycardia, increased cardiac dimensions, enhanced ventricular filling, augmentation of stroke volume and high peak oxygen consumption are recognised features of the athlete's heart. The type and magnitude of these adaptations to physical exercise are governed by age, sex, ethnicity, sporting discipline and intensity of sport. Some athletes, particularly those of African or Afro-Caribbean (black) origin reveal changes that overlap with diseases implicated in sudden cardiac death. In such instances, erroneous interpretation has potentially serious consequences ranging from unfair disqualification to false reassurance. This article focuses on ethnic variation in the physiological cardiac adaption to exercise.

[Electrocardiographic findings related to young Senegalese basketball players]

La pratique intensive et prolongée de sport peut induire des modifications cardiovasculaires et électrocardiographiques. L’objectif de ce travail était de décrire les modifications électrocardiographiques attribuables à la pratique de basket de compétition chez de jeunes noirs sénégalais. Les auteurs ont réalisé une étude prospective descriptive de l’électrocardiogramme (ECG) de surface de jeunes noirs sénégalais pratiquant le basket de compétition. Il s’agissait de 40 jeunes basketteurs, 20 filles et 20 garçons, dont la moyenne d’âge était respectivement de 17 ans ± 0,86 (extrêmes: 17 et 19 ans) et 15 ans ± 1,56 (extrêmes: 13 et 18 ans). La fréquence cardiaque était plus basse chez les garçons, 59 battements ± 9 battements (extrêmes: 42 et 85) que chez les filles 73 battements / min ± 11 battements (extrêmes: 50-95) (p = 0,0004). Les particularités suivantes ont été observées: des troubles de la repolarisation à type d’onde T négative de V1 à V4 dans 3 cas (7, 5%), une hypertrophie ventriculaire droite dans 1 cas (2,5%), une déviation axiale droite de QRS dans 1 cas (2,5%). La pratique intense et prolongée de basket entraîne des modifications électrocardiographiques chez le jeune noir sénégalais.

Abnormal ECG Findings in Athletes: Clinical Evaluation and Considerations

PURPOSE OF REVIEW

Pre-participation cardiovascular evaluation with electrocardiography is normal practice for most sporting bodies. Awareness about sudden cardiac death in athletes and recognizing how screening can help identify vulnerable athletes have empowered different sporting disciplines to invest in the wellbeing of their athletes.

RECENT FINDINGS

Discerning physiological electrical alterations due to athletic training from those representing cardiac pathology may be challenging. The mode of investigation of affected athletes is dependent on the electrical anomaly and the disease(s) in question. This review will highlight specific pathological ECG patterns that warrant assessment and surveillance, together with an in-depth review of the recommended algorithm for evaluation.

Electrocardiographic Findings in National Basketball Association Athletes

Importance

While it is known that long-term intensive athletic training is associated with cardiac structural changes that can be reflected on surface electrocardiograms (ECGs), there is a paucity of sport-specific ECG data. This study seeks to clarify the applicability of existing athlete ECG interpretation criteria to elite basketball players, an athlete group shown to develop significant athletic cardiac remodeling.

Objective

To generate normative ECG data for National Basketball Association (NBA) athletes and to assess the accuracy of athlete ECG interpretation criteria in this population.

Design, Setting, and Participants

The NBA has partnered with Columbia University Medical Center to annually perform a review of policy-mandated annual preseason ECGs and stress echocardiograms for all players and predraft participants. This observational study includes the preseason ECG examinations of NBA athletes who participated in the 2013-2014 and 2014-2015 seasons, plus all participants in the 2014 and 2015 NBA predraft combines. Examinations were performed from July 2013 to May 2015. Data analysis was performed between December 2015 and March 2017.

Exposures

Active roster or draft status in the NBA and routine preseason ECGs and echocardiograms.

Main Outcomes and Measures

Baseline quantitative ECG variables were measured and ECG data qualitatively analyzed using 3 existing, athlete-specific interpretation criteria: Seattle (2012), refined (2014), and international (2017). Abnormal ECG findings were compared with matched echocardiographic data.

Results

Of 519 male athletes, 409 (78.8%) were African American, 96 (18.5%) were white, and the remaining 14 (2.7%) were of other races/ethnicities; 115 were predraft combine participants, and the remaining 404 were on active rosters of NBA teams. The mean (SD) age was 24.8 (4.3) years. Physiologic, training-related changes were present in 462 (89.0%) athletes in the study. Under Seattle criteria, 131 (25.2%) had abnormal findings, compared with 108 (20.8%) and 81 (15.6%) under refined and international criteria, respectively. Increased age and increased left ventricular relative wall thickness (RWT) on echocardiogram were highly associated with abnormal ECG classifications; 17 of 186 athletes (9.1%) in the youngest age group (age 18-22 years) had abnormal ECGs compared with 36 of the 159 athletes (22.6%) in the oldest age group (age 27-39 years) (odds ratio, 2.9; 95% CI, 1.6-5.4; P < .001). Abnormal T-wave inversions (TWI) were present in 32 athletes (6.2%), and this was associated with smaller left ventricular cavity size and increased RWT. One of the 172 athletes (0.6%) in the lowest RWT group (range, 0.24-0.35) had TWIs compared with 24 of the 163 athletes (14.7%) in the highest RWT group (range, 0.41-0.57) (odds ratio, 29.5; 95% CI, 3.9-221.0; P < .001).

Conclusions and Relevance

Despite the improved specificity of the international recommendations over previous athlete-specific ECG criteria, abnormal ECG classification rates remain high in NBA athletes. The development of left ventricular concentric remodeling appears to have a significant influence on the prevalence of abnormal ECG classification and repolarization abnormalities in this athlete group.

Higher Prevalence of Abnormal Electrocardigrams (ECG) in African Americans Undergoing Screening ECG and Echocardiography

BACKGROUND

African American (AA) has higher prevalence of abnormal electrocardigrams (ECG) in general population. However, the degree of these abnormalities in a healthy population undergoing screening echocardiography is not known. The goal of this study was to evaluate the prevalence of ECG abnormalities reported during screening echocardiography based on race.

METHOD

The Anthony Bates Foundation has been performing screening across the United States for the prevention of sudden death since 2001. We evaluated a total of 633 participants with documented race and ECG for the presence of any abnormalities.

RESULTS

The age of the study population ranged between 6 and 75 years old. The prevalence of abnormal ECG in AA participant was 20.7% (12/58) versus 6.6% (38/578) in other races [odds ratio (OR), 3.70; confidence interval (CI), 1.8-7.58; P < 0.001]. Using multivariate analysis adjusting for age, sex, body mass index, left ventricular hypertrophy, and hypertension (systolic blood pressure >140 and diastolic blood pressure of >90), AA race remained independently associated with abnormal ECG (OR, 2.58; CI, 1.12-5.97; P = 0.02). Limiting our study only to teenagers (age, 13-19 years), AA race remained significantly associated with higher prevalence of ECG abnormalities [23.1% (12/58) of teenage AA had abnormal ECG vs. 7.5% (24/321) of other teenage races; OR, 3.71; CI, 1.36-10.11; P = 0.006]. After excluding benign ECG abnormalities such as sinus bradycardia and early repolarization, AA race remained significantly associated with higher prevalence of abnormal ECG (16.7% vs. 7.3%; OR, 2.52; CI, 0.998-6.39; P = 0.054).

CONCLUSIONS

The prevalence of abnormal ECG is higher in AA race independent of echocardiographic abnormalities or demographics. However, some of these abnormalities appear to be related to sinus bradycardia and early repolarization.

Pre-participation cardiovascular evaluation in Pacific Island athletes

BACKGROUND

Pre-participation cardiovascular evaluation (PPE) aims to detect cardiac disease with sudden cardiac death (SCD) risk. No study has focused on Pacific Island athletes.

METHODS

A total of 2281 Pacific Island athletes were studied with (i) a questionnaire on family, personal history and symptoms, (ii) a physical examination and (iii) a 12-lead ECG.

RESULTS

85% presented a normal history and examination. A positive family history was 1.4-1.9 fold higher in Melanesians, Polynesians and Métis than in Caucasians, while a positive personal history, abnormal symptoms and abnormal examination was 1.3 fold higher in Melanesians and Métis than in others. Neither gender nor training level had a bearing on these results. Melanesians had higher T wave inversions (TWIs) in V2-V4 leads but had no CV abnormalities. Lateral or infero-lateral TWIs were found in 6 male and in 5 highly trained athletes and cardiomyopathies were diagnosed in 3/6 athletes. Overall, 3.9% athletes were found to have a CV abnormality and 0.8% had a risk of SCD. Polynesians and males were more at risk than the others while the level of training made no difference. In athletes at risk of SCD, the main detected CV diseases were cardiomyopathies, Wolff-Parkinson-White (WPW) and severe valve lesions of rheumatoid origin.

CONCLUSIONS

PPE revealed that 3.9% presented CV abnormalities. A risk of SCD was found in 0.8% with cardiomyopathies, WPW, and severe valve lesions of rheumatoid origin. Melanesians, Polynesians and male of high level of training were more at risk than others.

Ethnic differences in the cardiac responses to aerobic exercise

Background: Cardiovascular disease disproportionately affects North American Indigenous populations. Ethnic differences in cardiac responses to exercise are known, though Indigenous populations response is unknown. To evaluate cardiac responses to aerobic exercise among Canadian Indigenous and European adults. Methods: Indigenous (N = 12, 4 females, 1 male incomplete) and European (N = 12, all completed) Canadian age and sex-matched adults 19-40 years and free of cardiovascular disease or diabetes completed a cycle ergometer maximal aerobic power test and 30 min at 60% maximal aerobic capacity on two separate days. Echocardiographic assessments preceded and immediately followed exercise. Results: Responses to maximal exercise were similar among ethnicities including decreases in stroke volume index, cardiac output index and ejection fraction, and increases in arterial-ventricular coupling. However, following submaximal exercise, only Indigenous adults demonstrated reductions in end systolic volume, end diastolic volume (154.8 ± 40.6 mL to 136.5 ± 33.0 mL, p = 0.01, vs. 149.4 ± 22.4 mL to 147.1 ± 27.0 mL; p = 0.81), stroke volume index (44.9 ± 8.7 mL m^-2 to 38.0 ± 6.5 mL m^-2, p = 0.002, vs. 46.4 ± 7.1 mL m^-2 to 44.0 ± 6.5 mL m^-2; p = 0.28) and arterial compliance. Conclusion: Indigenous and European adults demonstrated similar cardiac responses to maximal exercise, though only Indigenous adults demonstrated cardiac responses to submaximal exercise.

Prevalence and predictors of electrocardiogram abnormalities among athletes

Background Existing evidence, predominantly from Western countries, has demonstrated that athletes' hearts undergo structural, physiological, and electrical changes, leading to abnormal electrocardiogram readings that are said to be training-related. Athletes with non-training-related electrocardiographic abnormalities risk developing sudden cardiac death. The lack of studies on this issue in the Asian population warrants further exploration. Therefore, the aim of this study was to estimate the prevalence and predictive factors contributing to electrocardiogram abnormalities among athletes in Brunei. Methods A descriptive cross-sectional study was conducted on 100 athletes (median age 25.2 years) in 10 sporting disciplines, whose electrocardiogram readings and essential information was obtained. Results The prevalence of an abnormal electrocardiogram was 52% (95% confidence interval: 42.0%-62.0%), comprising training-related changes in 49% (95% confidence interval: 39.0%-59.0%) and non-training-related changes in 3% (95% confidence interval: 0.4%-6.4%). Athletes with a higher body mass index were 3.3-times (95% confidence interval: 1.47-9.58) more likely to have abnormal electrocardiogram readings. Athletes <25-years old (odds ratio = 0.25, 95% confidence interval: 0.07-0.81) and those who trained with low dynamic intensity (odds ratio = 0.33, 95% confidence interval: 0.12-0.93) were significantly less likely to have electrocardiogram abnormalities. Conclusions This is the first study reporting abnormal electrocardiograms among athletes in Brunei, which provides important information to relevant agencies involved in the preparation of Asian athletes for domestic or international competitions, particularly those with a higher body mass index and low dynamic training intensity.

Cardiac Screening of Young Athletes: a Practical Approach to Sudden Cardiac Death Prevention

PURPOSE OF REVIEW

We aim to report on the current status of cardiovascular screening of athletes worldwide and review the up-to-date evidence for its efficacy in reducing sudden cardiac death in young athletes.

RECENT FINDINGS

A large proportion of sudden cardiac death in young individuals and athletes occurs during rest with sudden arrhythmic death syndrome being recognised as the leading cause. The international recommendations for ECG interpretation have reduced the false-positive ECG rate to 3% and reduced the cost of screening by 25% without compromising the sensitivity to identify serious disease. There are some quality control issues that have been recently identified including the necessity for further training to guide physicians involved in screening young athletes. Improvements in our understanding of young sudden cardiac death and ECG interpretation guideline modification to further differentiate physiological ECG patterns from those that may represent underlying disease have significantly improved the efficacy of screening to levels that may make screening more attractive and feasible to sporting organisations as a complementary strategy to increased availability of automated external defibrillators to reduce the overall burden of young sudden cardiac death.

Progression of early repolarization patterns at a four year follow-up in a female flight crew population: Implications for aviation medicine

BACKGROUND

To assess the prevalence, the appearance, and the distribution, as well as the fluctuation over time of early repolarization patterns after four years in a female population derived from the French aviation sector.

METHODS

This was a retrospective longitudinal study from 1998 to 2010 of a population of female employees who received a full clinical examination and an electrocardiogram (ECG) upon their recruitment and after a period of four years.

RESULTS

A total of 306 women were included (average of 25.87 ± 3.3 years of age). The prevalence of early repolarization was 9.2%. The most common appearance was J-point slurring for 64.3% (i.e. 20/28 subjects) that occurred in the inferior leads for 28.6% (i.e. 8/28 subjects). After four years, the prevalence was 7.5%, with a regression of this aspect in five of the subjects. There were no changes in the ECG in terms of the distribution and the appearance among the 23 subjects for whom the aspect persisted. Over the course of this four year period all of the subjects remained asymptomatic.

CONCLUSIONS

Early repolarization in this largely physically inactive female population was common, and it fluctuated over time. At present, no particular restrictions can be placed on asymptomatic flight crew who exhibit this feature in the absence of a prior medical history for heart disease.

Electrical and structural adaptations of the paediatric athlete’s heart: a systematic review with meta-analysis

Aim

To describe the electrocardiographic (ECG) and echocardiographic manifestations of the paediatric athlete’s heart, and examine the impact of age, race and sex on cardiac remodelling responses to competitive sport.

Design

Systematic review with meta-analysis.

Data sources

Six electronic databases were searched to May 2016: MEDLINE, PubMed, EMBASE, Web of Science, CINAHL and SPORTDiscus.

Inclusion criteria

(1) Male and/or female competitive athletes, (2) participants aged 6–18 years, (3) original research article published in English language.

Results

Data from 14 278 athletes and 1668 non-athletes were included for qualitative (43 articles) and quantitative synthesis (40 articles). Paediatric athletes demonstrated a greater prevalence of training-related and training-unrelated ECG changes than non-athletes. Athletes ≥14 years were 15.8 times more likely to have inferolateral T-wave inversion than athletes <14 years. Paediatric black athletes had significantly more training-related and training-unrelated ECG changes than Caucasian athletes. Age was a positive predictor of left ventricular (LV) internal diameter during diastole, interventricular septum thickness during diastole, relative wall thickness and LV mass. When age was accounted for, these parameters remained significantly larger in athletes than non-athletes. Paediatric black athletes presented larger posterior wall thickness during diastole (PWTd) than Caucasian athletes. Paediatric male athletes also presented larger PWTd than females.

Conclusions

The paediatric athlete’s heart undergoes significant remodelling both before and during ‘maturational years’. Paediatric athletes have a greater prevalence of training related and training-unrelated ECG changes than non-athletes, with age, race and sex mediating factors on cardiac electrical and LV structural remodelling.

Normal computerized Q wave measurements in healthy young athletes

BACKGROUND

Recent Expert consensus statements have sought to decrease false positive rates of electrocardiographic abnormalities requiring further evaluation when screening young athletes. These statements are largely based on traditional ECG patterns and have not considered computerized measurements.

OBJECTIVE

To define the normal limits for Q wave measurements from the digitally recorded ECGs of healthy young athletes.

METHODS

All athletes were categorized by sex and level of participation (high school, college, and professional), and underwent screening ECGs with routine pre-participation physicals, which were electronically captured and analyzed. Q wave amplitude, area and duration were recorded for athletes with Q wave amplitudes greater than 0.5mm at standard paper amplitude display (1mV/10mm). ANOVA analyses were performed to determine differences these parameters among all groups. A positive ECG was defined by our Stanford Computerized Criteria as exceeding the 99th percentile for Q wave area in 2 or more leads. Proportions testing was used to compare the Seattle Conference Q wave criteria with our data-driven criteria.

RESULTS

2073 athletes in total were screened. Significant differences in Q wave amplitude, duration and area were identified both by sex and level of participation. When applying our Stanford Computerized Criteria and the Seattle criteria to our cohort, two largely different groups of athletes are identified as having abnormal Q waves.

CONCLUSION

Computer analysis of athletes' ECGs should be included in future studies that have greater numbers, more diversity and adequate end points.

Screening young athletes for prevention of sudden cardiac death: Practical recommendations for sports physicians

Regular intensive exercise in athletes increases the relative risk of sudden cardiac death (SCD) compared with the relatively sedentary population. Most cases of SCD are due to silent cardiovascular diseases, and pre-participation screening of athletes at risk of SCD is thus of major importance. However, medical guidelines and recommendations differ widely between countries. In Italy, the National Health System recommends pre-participation screening for all competitive athletes including personal and family history, a physical examination, and a resting 12-lead electrocardiogram (ECG). In the United States, the American College of Cardiology and the American Heart Association recommend a pre-participation screening program limited to the use of specific questionnaires and a clinical examination. The value of a 12-lead ECG is debated based on issues surrounding cost-efficiency and feasibility. The aim of this review was to focus on (i) the incidence rate of cardiac diseases in relation to SCD; (ii) the value of conducting a questionnaire and a physical examination; (iii) the value of a 12-lead resting ECG; (iv) the importance of other cardiac evaluations in the prevention of SCD; and (v) the best practice for pre-participation screening.

T wave inversions in athletes: a variety of scenarios

Athletic intensive exercise is associated with repolarization changes affecting the ST-segment and T-wave morphology. The prevalence and distribution of these alterations are influenced by several demographic factors. One of the most challenging conundrums for both the cardiologist and the sports medicine physician is the correct interpretation of these repolarization changes to prevent an erroneous diagnosis with potentially serious consequences. A 12-lead electrocardiogram (ECG) demonstrating inverted T-waves may represent the first and only sign of such inherited heart muscle diseases, and may precede the detection of any structural changes in the heart, however, T-wave inversion in leads V1-V4 in black athletes may represent ethnic variation which is exaggerated by exercise.

Prevalence and significance of isolated T wave inversion in 1755 consecutive American collegiate athletes

BACKGROUND

We evaluated the prevalence of isolated T-wave inversions (TWI) in American athletes using contemporary ECG criteria. Ethnic and gender disparities including the association of isolated TWI with underlying abnormal cardiac structure are evaluated.

METHODS

From 2004 to 2014, 1755 collegiate athletes at a single American university underwent prospective collection of medical history, physical examination, 12-lead ECG, and 2-dimensional echocardiography. ECG analysis was performed to evaluate for isolated TWI as per contemporary ECG criteria.

RESULTS

The overall prevalence of isolated TWI is 1.3%. Ethnic and gender disparities are not observed in American athletes (black vs. white: 1.7% vs. 1.1%; p=0.41) (women vs. men: 1.5% vs. 1.1; p=0.52). No association was found with underlying cardiomyopathy.

CONCLUSION

A lower prevalence of isolated TWI in American athletes than previously reported. Isolated TWI was not associated with an abnormal echocardiogram. No ethnic or gender disparity is seen in American college athletes.

T-wave reversion in pediatric patients during exercise stress testing

OBJECTIVE

T-wave inversion in lateral electrocardiogram (ECG) leads (II, III, aVF, V4 -V6 ) is suspicious of cardiac pathology in pediatric patients, though many are found to have structurally normal hearts. The purpose of this study is to evaluate T-wave response during exercise stress testing (EST) in pediatric patients with structurally normal hearts and lateral-lead T-wave inversion on resting ECG.

DESIGN

An IRB-approved, retrospective review of EST databases at two centers identified patients with lateral-lead T-wave inversion on resting ECG. Inclusion criteria were normal exam and echocardiogram, absence of anginal chest pain, and age <18 years. All patients underwent treadmill or cycle ergometer EST. Data recorded included demographics, echocardiogram results, baseline ECG, EST method, peak heart rate and metabolic equivalents (METs), and heart rate and METs at T-wave reversion. T-wave reversion was considered complete if T-waves reverted in all leads, partial if reversion occurred in only some leads, and none if no reversion occurred.

RESULTS

The search identified 14 patients: nine females and five males (10 Caucasians and four African Americans) and an average age of 16 (range 12-18) years. Complete T-wave reversion occurred in 11 (79%) patients, partial in two (14%), and none in one (7%). Reversion occurred in both genders, ethnicities, and EST methods. No complications occurred during EST; no adverse outcomes occurred during 2-year follow-up.

CONCLUSIONS

EST in pediatric patients with lateral-lead T-wave inversion on resting ECG and structurally and functionally normal hearts resulted in either complete or partial T-wave reversion in the vast majority of patients.

Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the American Heart Association

BACKGROUND AND PURPOSE

This American Heart Association (AHA) scientific statement provides a comprehensive overview of current evidence on the burden cardiovascular disease (CVD) among Hispanics in the United States. Hispanics are the largest minority ethnic group in the United States, and their health is vital to the public health of the nation and to achieving the AHA's 2020 goals. This statement describes the CVD epidemiology and related personal beliefs and the social and health issues of US Hispanics, and it identifies potential prevention and treatment opportunities. The intended audience for this statement includes healthcare professionals, researchers, and policy makers.

METHODS

Writing group members were nominated by the AHA's Manuscript Oversight Committee and represent a broad range of expertise in relation to Hispanic individuals and CVD. The writers used a general framework outlined by the committee chair to produce a comprehensive literature review that summarizes existing evidence, indicate gaps in current knowledge, and formulate recommendations. Only English-language studies were reviewed, with PubMed/MEDLINE as our primary resource, as well as the Cochrane Library Reviews, Centers for Disease Control and Prevention, and the US Census data as secondary resources. Inductive methods and descriptive studies that focused on CVD outcomes incidence, prevalence, treatment response, and risks were included. Because of the wide scope of these topics, members of the writing committee were responsible for drafting individual sections selected by the chair of the writing committee, and the group chair assembled the complete statement. The conclusions of this statement are the views of the authors and do not necessarily represent the official view of the AHA. All members of the writing group had the opportunity to comment on the initial drafts and approved the final version of this document. The manuscript underwent extensive AHA internal peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

This statement documents the status of knowledge regarding CVD among Hispanics and the sociocultural issues that impact all subgroups of Hispanics with regard to cardiovascular health. In this review, whenever possible, we identify the specific Hispanic subgroups examined to avoid generalizations. We identify specific areas for which current evidence was less robust, as well as inconsistencies and evidence gaps that inform the need for further rigorous and interdisciplinary approaches to increase our understanding of the US Hispanic population and its potential impact on the public health and cardiovascular health of the total US population. We provide recommendations specific to the 9 domains outlined by the chair to support the development of these culturally tailored and targeted approaches.

CONCLUSIONS

Healthcare professionals and researchers need to consider the impact of culture and ethnicity on health behavior and ultimately health outcomes. There is a need to tailor and develop culturally relevant strategies to engage Hispanics in cardiovascular health promotion and cultivate a larger workforce of healthcare providers, researchers, and allies with the focused goal of improving cardiovascular health and reducing CVD among the US Hispanic population.

The electrocardiographic manifestations of arrhythmogenic right ventricular dysplasia

The ECG is abnormal in most patients with arrhythmogenic right ventricular dysplasia (ARVD). Right ventricular parietal block, reduced QRS amplitude, epsilon wave, T wave inversion in V1-3 and ventricular tachycardia in the morphology of left bundle branch block are the characteristic changes that reflect the underlying genetic predetermined pathology and pathoelectrophysiology. Recognizing the characteristic ECG changes in ARVD will be of help in making a correct diagnosis of this rare disease.

Standardised pre-competitive screening of athletes in some European and African countries: the SMILE study

Most of the available data on the cardiovascular screening of athletes come from Italy, with fewer records being available outside of Italy and for non-Caucasian populations. The goals of the SMILE project (Sport Medicine Intervention to save Lives through ECG) are to evaluate the usefulness of 12-lead ECGs for the detection of cardiac diseases in athletes from three European countries and one African country and to estimate how many second-level examinations are needed subsequent to the initial screening in order to classify athletes with abnormal characteristics. A digital network consisting of Sport Centres and second and third opinion centres was set up in Greece, Germany, France and Algeria. Standard digital data input was carried out through the application of 12-lead ECGs, Bethesda questionnaires and physical examinations. Two hundred ninety-three of the 6,634 consecutive athletes required further evaluation, mostly (88.4 %) as a consequence of abnormal ECGs. After careful evaluation, 237 were determined to be healthy or apparently healthy, while 56 athletes were found to have cardiac disorders and were thus disqualified from active participation in sports. There was a large difference in the prevalence of diseases detected in Europe as compared with Algeria (0.23 and 4.01 %, respectively). Our data confirmed the noteworthy value of 12-lead resting ECGs as compared with other first-level evaluations, especially in athletes with asymptomatic cardiac diseases. Its value seems to have been even higher in Algeria than in the European countries. The establishment of a digital network of Sport Centres for second/third opinions in conjunction with the use of standard digital data input seems to be a valuable means for increasing the effectiveness of screening.

Exercise, the athlete's heart, and sudden cardiac death

Physical activity is a potent therapy for both the prevention and treatment of cardiovascular disease. Exercise appears to most benefit people who are the least active. There is some evidence to suggest that a curvilinear relationship exists between exercise and survival, whereby beyond an optimal level of fitness, the principle of diminishing returns applies. Indeed, some go further in suggesting that there is evidence that extreme athletic training may be harmful in some individuals. The incidence of sudden cardiac death in athletes is greater than in matched, nonathletic counterparts, and this finding is driven by the provocation of an underlying cardiac abnormality by strenuous exertion. The task of detecting pathological myocardial substrate in athletes is made difficult by physiological adaptations to exercise that can mimic the appearance of cardiomyopathies and ion channelopathies in some individuals. This article details the clinical evaluation of the athlete with reference limits for cardiac physiological remodeling and discusses the diagnostic dilemmas that arise.

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

Background—

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.

Methods and Results—

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.

Conclusion—

Refinement of current ECG screening criteria has the potential to significantly reduce the burden of false-positive ECGs in athletes, particularly BAs.

Impact of ethnicity on cardiac adaptation to exercise

The increasing globalization of sport has resulted in athletes from a wide range of ethnicities emerging onto the world stage. Fuelled by the untimely death of a number of young professional athletes, data generated from the parallel increase in preparticipation cardiovascular evaluation has indicated that ethnicity has a substantial influence on cardiac adaptation to exercise. From this perspective, the group most intensively studied comprises athletes of African or Afro-Caribbean ethnicity (black athletes), an ever-increasing number of whom are competing at the highest levels of sport and who often exhibit profound electrical and structural cardiac changes in response to exercise. Data on other ethnic cohorts are emerging, but remain incomplete. This Review describes our current knowledge on the impact of ethnicity on cardiac adaptation to exercise, starting with white athletes in whom the physiological electrical and structural changes--collectively termed the 'athlete's heart'--were first described. Discussion of the differences in the cardiac changes between ethnicities, with a focus on black athletes, and of the challenges that these variations can produce for the evaluating physician is also provided. The impact of ethnically mediated changes on preparticipation cardiovascular evaluation is highlighted, particularly with respect to false positive results, and potential genetic mechanisms underlying racial differences in cardiac adaptation to exercise are described.

Sudden cardiac death in athletes

A 'paradox of sport' is that in addition to the undisputed health benefits of physical activity, vigorous exertion may transiently increase the risk of acute cardiac events. In general, the risk of sudden cardiac death (SCD) approximately doubles during physical activity and is 2- to 3-fold higher in athletes compared to nonathletes. The incidence of SCD in young athletes is in fact very low, at around 1-3 per 100,000, but attracts much public attention. Variations in incidence figures may be explained by the methodology used for data collection and more importantly by differences between subpopulations of athletes. The incidence of SCD in older (≥ 35 years) athletes is higher and may be expected to rise, as more and older individuals take part in organized sports. SCD is often the first clinical manifestation of a potentially fatal underlying cardiovascular disorder and usually occurs in previously asymptomatic athletes. In the young (<35 years), SCD is mainly due to congenital/inherited cardiac abnormalities, whilst coronary artery disease (CAD) is the most common cause in older athletes. Cardiac screening including family/personal history, physical examination and resting electrocardiogram (ECG) may identify individuals at risk and has the potential to decrease the risk of SCD in young athletes. Screening including the ECG has a high sensitivity for underlying disease in young athletes, but the specificity needs to be improved, whereas the sensitivity of screening without the use of ECG is very low. The screening modality recommended for young athletes is of limited value in older athletes, who should receive individualized screening with cardiac stress testing for patients with high risk of underlying CAD. As cardiovascular screening will never be able to identify all athletes at risk, adequate preparedness is vital in case of a potentially fatal event at the sporting arena/facility. Firstly, we will review the magnitude of the problem of SCD in athletes of different ages, as well as the aetiology. Secondly, we will focus on how to prevent SCD in athletes of all ages, reviewing cardiovascular screening recommendations as well as emergency preparedness and arena safety.

High prevalence of hypertension among collegiate football athletes

BACKGROUND

The prevalence of hypertension among collegiate football athletes is not well described.

METHODS AND RESULTS

A retrospective cohort of all male athletes who participated in varsity athletics at a National Collegiate Athletic Association Division I university between 1999 and 2012 was examined through chart review. Mandatory annual preparticipation physical examinations included blood pressure, body mass index, medication use, and supplement use. Prevalence of hypertension was compared between football and nonfootball athletes. A mixed-effects linear regression model examined change in blood pressure over time. Six hundred thirty-six collegiate athletes, including 323 football players, were identified. In the initial year of athletic participation, 19.2% of football athletes had hypertension and 61.9% had prehypertension. The prevalence of hypertension was higher among football athletes than in nonfootball athletes in their initial (19.2% versus 7.0%; P<0.001) and final (19.2% versus 10.2%; P=0.001) years of athletic participation. In adjusted analyses, the odds of hypertension were higher among football athletes in the initial year (adjusted odds ratio, 2.28; 95% confidence interval, 1.21-4.30) but not in the final year (adjusted odds ratio, 1.25; 95% confidence interval, 0.69-2.28). Over the course of their collegiate career, football athletes had an annual decrease in systolic blood pressure (-0.82 mm Hg; P=0.002), whereas nonfootball athletes did not (0.18 mm Hg; P=0.58).

CONCLUSIONS

Hypertension and prehypertension were common among collegiate football athletes, and football athletes were more likely to have hypertension compared with male nonfootball athletes. This presents a potential cardiovascular risk in a young population of athletes. Strategies for increasing awareness, prevention, and treatment are needed.

Association between cardiac dimensions and athlete lineup position: analysis using echocardiography in NCAA football team players

In determining what is "abnormal"-in terms of cardiac electrical and morphologic remodeling in athletes-it is important to identify what is "normal" or expected. With specialization for each position in a football team lineup, we attempted to describe the association between the position played and the physiologic cardiac changes of designated players. We evaluated data from 85 National College Athletic Association football players from a single team. The participants were assigned to 1 of 3 groups based on position and training regimen: lineman (n = 34), mobility/power players (n = 13), and skill players (n = 38). Players underwent assessment with electrocardiography and echocardiography (ECHO), with results interpreted by reviewers blinded to players' positions. Linemen were found to have greater body mass index and body surface area (BSA), as well as longer QRS duration (102 ± 10 ms vs 101 ± 7 ms in mobility/power players, and 96 ± 7 ms in skill players; P < 0.007). Left ventricular (LV) voltage values were lower in linemen (27.7 ± 6.5 mV vs 28.8 ± 7 mV in mobility/power players, and 31.8 ± 7.6 mV in skill players; both, P < 0.05). No differences in ejection fraction between groups were revealed on ECHO, but ECHO did show greater calculated LV mass, LV end-diastolic diameter, aortic root diameter, and LV outflow tract diameter in linemen, whether adjusted for BSA or not, and the differences were statistically different. Multivariate analysis showed that position (P < 0.0004 and QRS duration (P = 0.03) predicted LV mass. Echocardiographic variables found to be associated with player position included LV mass adjusted for BSA (P < 0.0001), LV end-diastolic diameter adjusted for BSA (P < 0.0003), and QTc interval (P = 0.007). On multivariate analysis, racial identity did not demonstrate significant differences; however, differences existed on univariate analysis of electrocardiography and ECHO variables, mostly in skill players. In skill players, QRS duration was shorter in the African American (AA) subgroup compared with that in the white/other subgroup. Lateral ST elevation and LV end-systolic volume were greater in AA players after adjustment for BSA, and AA linemen had greater LV posterior wall thickness after adjustment for BSA. In summary, we found that football players who are linemen had greater heart mass than did other players, despite adjustments for body size.

Exercise and heart disease: from athletes and arrhythmias to hypertrophic cardiomyopathy and congenital heart disease

The beneficial effects of regular physical activity on cardiovascular health are well established, with convincing evidence of improvements in blood pressure, lipid profile and overall mortality. Conversely, individuals with pre-existing congenital, inherited or acquired heart conditions may experience functional cardiac deterioration or sudden death during even moderate exertion. Exclusion from high-level sporting activity may be mandated in some cases, and pre-participation screening of competitive athletes plays an important role in the identification of such individuals. The issue of screening is complicated by the fact that physiological cardiovascular adaptation in healthy athletes, including modest left ventricular hypertrophy and biventricular cavity dilatation, may create a diagnostic overlap with pathological conditions such as hypertrophic cardiomyopathy. Furthermore, much interest has focused recently on the possibility of irreversible cardiac remodeling in a proportion of veteran endurance athletes, with the potential for arrhythmogenesis and adverse cardiac events.

Cardiac adaptation to exercise in adolescent athletes of African ethnicity: an emergent elite athletic population

BACKGROUND/AIMS

Adult black athletes (BA) exhibit left ventricular hypertrophy (LVH) on echocardiography and marked ECG repolarisation changes resembling those observed in hypertrophic cardiomyopathy (HCM). Limited data are available for adolescent BA, the group most vulnerable to exercise-related sudden cardiac death.

METHODS

Between 1996 and 2011, 245 male and 84 female adolescent BA from a wide variety of sporting disciplines underwent cardiac evaluation including ECG and echocardiography. Athletes exhibiting T-wave inversions and/or echocardiographic LVH were investigated further for quiescent cardiomyopathies. Results were compared with 903 adolescent white athletes (WA) and 134 adolescent sedentary black controls (BC).

RESULTS

LVH on echocardiography was present in 7% of BA compared to only 0.6% of WA and none of the BC. In the very young (<16 years), 5.5% of BA, but none of the WA, demonstrated LVH. Within the BA group, LVH was more prevalent in men compared to women (9% vs 1.2%, p=0.012). T-wave inversions were present in 22.8% BA, 4.5% WA and 13.4% BC. T-wave inversions in BA occurred with similar frequency in men and women and were predominantly confined to leads V1-V4. T-wave inversions in the lateral leads, commonly associated with cardiomyopathies, were present in 2.4% of BA. On a further evaluation and mean follow-up of 8.3 years, none of the athletes exhibited HCM.

CONCLUSIONS

Athletic training has a pronounced effect on adolescent BA. Black athletes as young as 14 years of age may exhibit left ventricular wall thicknesses of 15 mm and marked repolarisation changes resembling HCM. Male and female BA demonstrate a high prevalence of T-wave inversions.