1
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Tso JV, Montalvo S, Christle J, Hadley D, Froelicher V. Should ECG criteria for Low QRS voltage (LQRSV) be specific for Sex? Am Heart J 2024; 270:117-124. [PMID: 38342392 DOI: 10.1016/j.ahj.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 02/03/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
INTRODUCTION Low QRS peak-to-nadir voltage (LQRSV) is associated with arrhythmogenic right ventricular cardiomyopathy (ARVC) and other cardiomyopathies. Recent studies have proposed criteria for LQRSV when screening athletes for cardiovascular disease. These criteria have not yet been evaluated in a large population of healthy young athletes. METHODS The target population was 10,728 (42.5% female, 57.5% male, mean age 18.1 ± 4.3 years) athletes who participated in mass ECG screenings between 2014 and 2021 at multiple sites across the United States including grade schools (11%), high schools (32%), colleges (50%), and professional athletic teams (6%) with digitally recorded ECGs and a standardized protocol. Since by design, complete follow up for outcomes and the results of testing were not available. Including only ECGs from initial evaluation among athletes 14-35 years of age and excluding those with right bundle branch block, left bundle branch block, Wolf-Parkinson-White pattern, reversed leads and 3 clinically diagnosed cardiomyopathies at Stanford, 8,679 (58% males, 42% females) remained eligible for analysis. QRS voltage was analyzed for each ECG lead and LQRSV criteria were applied and stratified by sex. RESULTS QRS voltage was lower in all leads in female athletes compared to male athletes. Using traditional limb lead criteria or precordial lead criteria, the prevalence of LQRSV was significantly lower in males than females (P < .001). Strikingly, LQRSV using the Sokolow-Lyon Index was present in 1.9% of males and 9.8% of females (P < .001). Applying first percentile for LQRS amplitude criteria provided possible values for screening young athletes for LQRSV. CONCLUSIONS LQRSV is more common among female athletes than male athletes using established criteria. Using first percentile sex-specific cut points should be considered in future analyses. Proposed novel LQRSV criteria in young athletes should be specific for males and females.
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Affiliation(s)
- Jason V Tso
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Samuel Montalvo
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Jeffrey Christle
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA
| | | | - Victor Froelicher
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA; Cardiac Insight Inc, Seattle, WA.
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2
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Ilodibia TF, Riding N. Anterior T-wave inversion in black athletes: an African perspective. Br J Sports Med 2024; 58:295-296. [PMID: 38290797 DOI: 10.1136/bjsports-2023-107585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 02/01/2024]
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3
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Petek BJ, Drezner JA, Churchill TW. The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions. Card Electrophysiol Clin 2024; 16:35-49. [PMID: 38280813 DOI: 10.1016/j.ccep.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan A Drezner
- University of Washington Medical Center for Sports Cardiology, Massachusetts General Hospital, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA 98195, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA.
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4
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Aljehani A, Baig S, Kew T, Kalla M, Sommerfeld LC, Murukutla VA, Fabritz L, Steeds RP. Structural Progression in Patients with Definite and Non-Definite Arrhythmogenic Right Ventricular Cardiomyopathy and Risk of Major Adverse Cardiac Events. Biomedicines 2024; 12:328. [PMID: 38397930 PMCID: PMC10886648 DOI: 10.3390/biomedicines12020328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/17/2023] [Accepted: 01/18/2024] [Indexed: 02/25/2024] Open
Abstract
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare inherited disease characterised by early arrhythmias and structural changes. Still, there are limited echocardiography data on its structural progression. We studied structural progression and its impact on the occurrence of major adverse cardiovascular events (MACE). In this single-centre observational cohort study, structural progression was defined as the development of new major or minor imaging 2010 Task Force Criteria during follow-up. Of 101 patients, a definite diagnosis of ARVC was made in 51 patients, while non-definite 'early' disease was diagnosed in 50 patients. During 4 years of follow-up (IQR: 2-6), 23 (45%) patients with a definite diagnosis developed structural progression while only 1 patient in the non-definite (early) group gained minor imaging Task Force Criteria. Male gender was strongly associated with structural progression (62% of males progressed structurally, while 88% of females remained stable). Patients with structural progression were at higher risk of MACE (64% of patients with MACE had structural progression). Therefore, the rate of structural progression is an essential factor to be considered in ARVC studies.
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Affiliation(s)
- Areej Aljehani
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth, Birmingham B15 2GW, UK
- Echocardiography Cardiovascular Technology (ECVT) Program, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia
| | - Shanat Baig
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth, Birmingham B15 2GW, UK
| | - Tania Kew
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth, Birmingham B15 2GW, UK
| | - Manish Kalla
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth, Birmingham B15 2GW, UK
| | - Laura C. Sommerfeld
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- University Center of Cardiovascular Science & Department of Cardiology, University Heart and Vascular Center and University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- German Centre for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Luebeck, 20246 Hamburg, Germany
| | - Vaishnavi Ameya Murukutla
- University Center of Cardiovascular Science & Department of Cardiology, University Heart and Vascular Center and University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- German Centre for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Luebeck, 20246 Hamburg, Germany
| | - Larissa Fabritz
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth, Birmingham B15 2GW, UK
- University Center of Cardiovascular Science & Department of Cardiology, University Heart and Vascular Center and University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- German Centre for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Luebeck, 20246 Hamburg, Germany
| | - Richard P. Steeds
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth, Birmingham B15 2GW, UK
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5
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Aimo A, Milandri A, Barison A, Pezzato A, Morfino P, Vergaro G, Merlo M, Argirò A, Olivotto I, Emdin M, Finocchiaro G, Sinagra G, Elliott P, Rapezzi C. Electrocardiographic abnormalities in patients with cardiomyopathies. Heart Fail Rev 2024; 29:151-164. [PMID: 37848591 PMCID: PMC10904564 DOI: 10.1007/s10741-023-10358-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 10/19/2023]
Abstract
Abnormalities in impulse generation and transmission are among the first signs of cardiac remodeling in cardiomyopathies. Accordingly, 12-lead electrocardiogram (ECG) of patients with cardiomyopathies may show multiple abnormalities. Some findings are suggestive of specific disorders, such as the discrepancy between QRS voltages and left ventricular (LV) mass for cardiac amyloidosis or the inverted T waves in the right precordial leads for arrhythmogenic cardiomyopathy. Other findings are less sensitive and/or specific, but may orient toward a specific diagnosis in a patient with a specific phenotype, such as an increased LV wall thickness or a dilated LV. A "cardiomyopathy-oriented" mindset to ECG reading is important to detect the possible signs of an underlying cardiomyopathy and to interpret correctly the meaning of these alterations, which differs in patients with cardiomyopathies or other conditions.
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Affiliation(s)
- Alberto Aimo
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | | | - Andrea Barison
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Andrea Pezzato
- Center for Diagnosis and Management of Cardiomyopathies, Cardiothoracovascular Department Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Paolo Morfino
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Giuseppe Vergaro
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Marco Merlo
- Center for Diagnosis and Management of Cardiomyopathies, Cardiothoracovascular Department Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | | | - Iacopo Olivotto
- Department of Experimental and Clinical Medicine, University of Florence, Meyer Children Hospital Florence, Florence, Italy
| | - Michele Emdin
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Gherardo Finocchiaro
- Royal Brompton and Harefield Hospital, London, UK
- St George's University of London, London, UK
| | - Gianfranco Sinagra
- Center for Diagnosis and Management of Cardiomyopathies, Cardiothoracovascular Department Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Perry Elliott
- UCL Centre for Heart Muscle Disease and Lead of the Inherited Cardiovascular Disease Unit, Bart's Heart Centre, London, UK
- Cardiology Centre, University of Ferrara, Ferrara, Italy
| | - Claudio Rapezzi
- UCL Centre for Heart Muscle Disease and Lead of the Inherited Cardiovascular Disease Unit, Bart's Heart Centre, London, UK
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6
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Arbelo E, Protonotarios A, Gimeno JR, Arbustini E, Barriales-Villa R, Basso C, Bezzina CR, Biagini E, Blom NA, de Boer RA, De Winter T, Elliott PM, Flather M, Garcia-Pavia P, Haugaa KH, Ingles J, Jurcut RO, Klaassen S, Limongelli G, Loeys B, Mogensen J, Olivotto I, Pantazis A, Sharma S, Van Tintelen JP, Ware JS, Kaski JP. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J 2023; 44:3503-3626. [PMID: 37622657 DOI: 10.1093/eurheartj/ehad194] [Citation(s) in RCA: 213] [Impact Index Per Article: 213.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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7
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Nielsen MS, van Opbergen CJM, van Veen TAB, Delmar M. The intercalated disc: a unique organelle for electromechanical synchrony in cardiomyocytes. Physiol Rev 2023; 103:2271-2319. [PMID: 36731030 PMCID: PMC10191137 DOI: 10.1152/physrev.00021.2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 01/24/2023] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
The intercalated disc (ID) is a highly specialized structure that connects cardiomyocytes via mechanical and electrical junctions. Although described in some detail by light microscopy in the 19th century, it was in 1966 that electron microscopy images showed that the ID represented apposing cell borders and provided detailed insight into the complex ID nanostructure. Since then, much has been learned about the ID and its molecular composition, and it has become evident that a large number of proteins, not all of them involved in direct cell-to-cell coupling via mechanical or gap junctions, reside at the ID. Furthermore, an increasing number of functional interactions between ID components are emerging, leading to the concept that the ID is not the sum of isolated molecular silos but an interacting molecular complex, an "organelle" where components work in concert to bring about electrical and mechanical synchrony. The aim of the present review is to give a short historical account of the ID's discovery and an updated overview of its composition and organization, followed by a discussion of the physiological implications of the ID architecture and the local intermolecular interactions. The latter will focus on both the importance of normal conduction of cardiac action potentials as well as the impact on the pathophysiology of arrhythmias.
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Affiliation(s)
- Morten S Nielsen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Chantal J M van Opbergen
- The Leon Charney Division of Cardiology, New York University Grossmann School of Medicine, New York, New York, United States
| | - Toon A B van Veen
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mario Delmar
- The Leon Charney Division of Cardiology, New York University Grossmann School of Medicine, New York, New York, United States
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8
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Petek BJ, Drezner JA, Churchill TW. The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions. Cardiol Clin 2023; 41:35-49. [PMID: 36368810 PMCID: PMC10292923 DOI: 10.1016/j.ccl.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.
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Affiliation(s)
- Bradley J Petek
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA
| | - Jonathan A Drezner
- University of Washington Medical Center for Sports Cardiology, Massachusetts General Hospital, 3800 Montlake Boulevard Northeast, Box 354060, Seattle, WA 98195, USA
| | - Timothy W Churchill
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiovascular Performance Program, Massachusetts General Hospital, Yawkey Suite 5B, 55 Fruit Street, Boston, MA 02114, USA.
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9
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Quintella Sangiorgi Olivetti N, Sacilotto L, Wulkan F, D'Arezzo Pessente G, Lombardi Peres de Carvalho M, Moleta D, Tessariol Hachul D, Veronese P, Hardy C, Pisani C, Wu TC, Vieira MLC, de França LA, de Souza Freitas M, Rochitte CE, Bueno SC, Bastos Lovisi V, Krieger JE, Scanavacca M, da Costa Pereira A, da Costa Darrieux F. Clinical Features, Genetic Findings, and Risk Stratification in Arrhythmogenic Right Ventricular Cardiomyopathy: Data From a Brazilian Cohort. Circ Arrhythm Electrophysiol 2023; 16:e011391. [PMID: 36720007 DOI: 10.1161/circep.122.011391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Arrhythmogenic right ventricular cardiomyopathy (ARVC), a rare inherited disease, causes ventricular tachycardia, sudden cardiac death, and heart failure (HF). We investigated ARVC clinical features, genetic findings, natural history, and the occurrence of life-threatening arrhythmic events (LTAEs), HF death, or heart transplantation (HF-death/HTx) to identify risk factors. METHODS The clinical course of 111 consecutive patients with definite ARVC, predictors of LTAE, HF-death/HTx, and combined events were analyzed in the entire cohort and in a subgroup of 40 patients without sustained ventricular arrhythmia before diagnosis. RESULTS The 5-year cumulative probability of LTAE was 30% and HF-death/HTx was 10%. Predictors of HF-death/HTx were reduced right ventricle ejection fraction (HR: 0.93; P=0.010), HF symptoms (HR: 4.37; P=0.010), epsilon wave (HR: 4.99; P=0.015), and number of leads with low QRS voltage (HR: 1.28; P=0.001). Each additional lead with low QRS voltage increased the risk of HF-death/HTx by 28%. Predictors of LTAE were prior syncope (HR: 1.81; P=0.040), number of leads with T wave inversion (HR: 1.17; P=0.039), low QRS voltage (HR: 1.12; P=0.021), younger age (HR: 0.97; P=0.006), and prior ventricular arrhythmia/ventricular fibrillation (HR: 2.45; P=0.012). Each additional lead with low QRS voltage increased the risk of LTAE by 17%. In patients without ventricular arrhythmia before clinical diagnosis of ARVC, the number of leads with low QRS voltage (HR: 1.68; P=0.023) was independently associated with HF-death/HTx. CONCLUSIONS Our study demonstrated the characteristics of a specific cohort with a high prevalence of arrhythmic burden at presentation, male predominance, younger age and HF severe outcomes. Our main results suggest that the presence and extension of low QRS voltage can be a risk predictor for HF-death/HTx in ARVC patients, regardless of the arrhythmic risk. This study can contribute to the global ARVC risk stratification, adding new insights to the international current scientific knowledge.
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Affiliation(s)
- Natália Quintella Sangiorgi Olivetti
- Arrhythmia Unit (N.Q.S.O., L.S., G.D.P., D.T.H., P.V., C.H., C.P., T.C.W., S.C.B., V.B.L., M.S., F.d.C.D.).,Laboratory of Genetics and Molecular Cardiology (LGMC) (N.Q.S.O., F.W., M.L.P.d.C., J.E.K., A.d.C.P.)
| | - Luciana Sacilotto
- Arrhythmia Unit (N.Q.S.O., L.S., G.D.P., D.T.H., P.V., C.H., C.P., T.C.W., S.C.B., V.B.L., M.S., F.d.C.D.)
| | - Fanny Wulkan
- Laboratory of Genetics and Molecular Cardiology (LGMC) (N.Q.S.O., F.W., M.L.P.d.C., J.E.K., A.d.C.P.)
| | - Gabrielle D'Arezzo Pessente
- Arrhythmia Unit (N.Q.S.O., L.S., G.D.P., D.T.H., P.V., C.H., C.P., T.C.W., S.C.B., V.B.L., M.S., F.d.C.D.)
| | | | - Danilo Moleta
- Echocardiogram Imaging Unit (D.B.M., M.L.C.V.).,Echocardiogram Imaging Unit, Hospital Israelita Albert Einstein. São Paulo, Brazil (D.B.M., M.L.C.V., L.A.d.F.)
| | - Denise Tessariol Hachul
- Arrhythmia Unit (N.Q.S.O., L.S., G.D.P., D.T.H., P.V., C.H., C.P., T.C.W., S.C.B., V.B.L., M.S., F.d.C.D.)
| | - Pedro Veronese
- Arrhythmia Unit (N.Q.S.O., L.S., G.D.P., D.T.H., P.V., C.H., C.P., T.C.W., S.C.B., V.B.L., M.S., F.d.C.D.)
| | - Carina Hardy
- Arrhythmia Unit (N.Q.S.O., L.S., G.D.P., D.T.H., P.V., C.H., C.P., T.C.W., S.C.B., V.B.L., M.S., F.d.C.D.)
| | - Cristiano Pisani
- Arrhythmia Unit (N.Q.S.O., L.S., G.D.P., D.T.H., P.V., C.H., C.P., T.C.W., S.C.B., V.B.L., M.S., F.d.C.D.)
| | - Tan Chen Wu
- Arrhythmia Unit (N.Q.S.O., L.S., G.D.P., D.T.H., P.V., C.H., C.P., T.C.W., S.C.B., V.B.L., M.S., F.d.C.D.)
| | - Marcelo Luiz Campos Vieira
- Echocardiogram Imaging Unit (D.B.M., M.L.C.V.).,Echocardiogram Imaging Unit, Hospital Israelita Albert Einstein. São Paulo, Brazil (D.B.M., M.L.C.V., L.A.d.F.)
| | - Lucas Arraes de França
- Echocardiogram Imaging Unit, Hospital Israelita Albert Einstein. São Paulo, Brazil (D.B.M., M.L.C.V., L.A.d.F.)
| | - Matheus de Souza Freitas
- Division of Cardiovascular Magnetic Ressonance Imaging, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.d.S.F., C.E.R.)
| | - Carlos Eduardo Rochitte
- Division of Cardiovascular Magnetic Ressonance Imaging, Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.d.S.F., C.E.R.)
| | - Sávia Christina Bueno
- Arrhythmia Unit (N.Q.S.O., L.S., G.D.P., D.T.H., P.V., C.H., C.P., T.C.W., S.C.B., V.B.L., M.S., F.d.C.D.)
| | - Vitor Bastos Lovisi
- Arrhythmia Unit (N.Q.S.O., L.S., G.D.P., D.T.H., P.V., C.H., C.P., T.C.W., S.C.B., V.B.L., M.S., F.d.C.D.)
| | - José Eduardo Krieger
- Laboratory of Genetics and Molecular Cardiology (LGMC) (N.Q.S.O., F.W., M.L.P.d.C., J.E.K., A.d.C.P.)
| | - Maurício Scanavacca
- Arrhythmia Unit (N.Q.S.O., L.S., G.D.P., D.T.H., P.V., C.H., C.P., T.C.W., S.C.B., V.B.L., M.S., F.d.C.D.)
| | | | - Francisco da Costa Darrieux
- Arrhythmia Unit (N.Q.S.O., L.S., G.D.P., D.T.H., P.V., C.H., C.P., T.C.W., S.C.B., V.B.L., M.S., F.d.C.D.)
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10
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Zorzi A, Bettella N, Tatangelo M, Del Monte A, Vessella T, Poscolieri B, Crescenzi C, Pegorin D, D'Ascenzi F, Pescatore V, Giada F, Sarto P, Calò L, Schiavon M, Gregori D, Hadley DM, Drezner JA, Pelliccia A, Corrado D. Prevalence and clinical significance of isolated low QRS voltages in young athletes. Europace 2022; 24:1484-1495. [PMID: 35243505 PMCID: PMC9559913 DOI: 10.1093/europace/euab330] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Indexed: 01/02/2023] Open
Abstract
AIMS Low QRS voltages (peak to peak <0.5 mV) in limb leads (LQRSV) on the athlete's electrocardiogram (ECG) may reflect an underlying cardiomyopathy, mostly arrhythmogenic cardiomyopathy (ACM) or non-ischaemic left ventricular scar (NILVS). We studied the prevalence and clinical meaning of isolated LQRSV in a large cohort of competitive athletes. METHODS AND RESULTS The index group included 2229 Italian competitive athletes [median age 18 years (16-25), 67% males, 97% Caucasian] without major ECG abnormalities at pre-participation screening. Three control groups included Black athletes (N = 1115), general population (N = 1115), and patients with ACM or NILVS (N = 58). Echocardiogram was performed in all athletes with isolated LQRSV and cardiac magnetic resonance (CMR) in those with ventricular arrhythmias or echocardiographic abnormalities. The isolated LQRSV pattern was found in 1.1% index athletes and was associated with increasing age (median age 28 vs. 18 years; P < 0.001), elite status (71% vs. 34%; P < 0.001), body surface area, and body mass index but not with sex, type of sport, and echocardiographic left ventricular mass. The prevalence of isolated LQRSV was 0.2% in Black athletes and 0.3% in young individuals from the general population. Cardiomyopathy patients had a significantly greater prevalence of isolated LQRSV (12%) than index athletes, Black athletes, and general population. Five index athletes with isolated LQSRV and exercise-induced ventricular arrhythmias underwent CMR showing biventricular ACM in 1 and idiopathic NILVS in 1. CONCLUSIONS Unlike cardiomyopathy patients, the ECG pattern of isolated LQRSV was rarely observed in athletes. This ECG sign should prompt clinical work-up for exclusion of an underlying cardiomyopathy.
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Affiliation(s)
- Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35121 Padova, Italy
| | - Natascia Bettella
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35121 Padova, Italy
| | | | - Alvise Del Monte
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35121 Padova, Italy
| | | | | | | | - Davide Pegorin
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35121 Padova, Italy
| | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Italy
| | | | - Franco Giada
- Sports Medicine Unit, ULSS3 Venezia, Venezia, Italy
| | | | | | | | - Dario Gregori
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35121 Padova, Italy
| | - David M Hadley
- Research & Development Department, Cardiac Insight Inc., Bellevue, WA, USA
| | - Jonathan A Drezner
- Center for Sports Cardiology, University of Washington, Seattle, WA, USA
| | | | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35121 Padova, Italy
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11
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Eberly L, Garg L, Vidula M, Reza N, Krishnan S. Running the Risk: Exercise and Arrhythmogenic Cardiomyopathy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022; 23. [PMID: 35082480 DOI: 10.1007/s11936-021-00943-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Purpose of review The purpose of this review is to summarize what is known about the relationship between exercise and arrhythmogenic right ventricular cardiomyopathy (ARVC) with regard to disease onset, diagnosis, progression, and clinical severity. This relationship forms the basis of the management recommendations for restricting physical activity in individuals with and at risk for ARVC. Recent findings While ARVC can be challenging to diagnose, there are several diagnostic testing and imaging modalities that may help distinguish athletic heart remodeling from ARVC. There is an increased risk of adverse clinical outcomes in ARVC from endurance and competitive sports participation, including a dose-dependent relationship between exercise intensity and risk of disease penetrance and progression. Summary High-intensity exercise can lead to earlier disease onset, increased penetrance, and clinical progression among individuals with and at risk for ARVC. Both amount and intensity of exercise are correlated with adverse outcomes, including ventricular arrhythmias and worsening biventricular function. All individuals with and at risk for ARVC should undergo detailed clinical phenotyping and risk stratification to reduce the risk of such outcomes, including sudden cardiac death. Consensus guidelines recommend against participation in competitive or high-intensity and endurance exercise for individuals with and at risk for ARVC.
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Affiliation(s)
- Lauren Eberly
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA, USA.,Penn Cardiovascular Center for Health Equity and Justice, University of Pennsylvania, Philadelphia, PA, USA
| | - Lohit Garg
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mahesh Vidula
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Sheela Krishnan
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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12
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Allwood RP. Differentiating right ventricular remodelling from cardiac pathology in athletes. SONOGRAPHY 2022. [DOI: 10.1002/sono.12299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Richard P. Allwood
- Cardiology Department St Vincent's Hospital Melbourne Melbourne Victoria Australia
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13
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A Novel Diagnostic Score Integrating Atrial Dimensions to Differentiate between the Athlete's Heart and Arrhythmogenic Right Ventricular Cardiomyopathy. J Clin Med 2021; 10:jcm10184094. [PMID: 34575205 PMCID: PMC8472715 DOI: 10.3390/jcm10184094] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 12/22/2022] Open
Abstract
Objective: The 2010 Task Force Criteria (TFC) have not been tested to differentiate ARVC from the athlete’s heart. Moreover, some criteria are not available (myocardial biopsy, genetic testing, morphology of ventricular tachycardia) or subject to interobserver variability (right ventricular regional wall motion abnormalities) in clinical practice. We hypothesized that atrial dimensions are useful and robust to differentiate between both entities and proposed a new diagnostic score based upon readily available parameters including echocardiographic atrial dimensions. Methods: In this observational study, 21 patients with definite ARVC were matched for age, gender and body mass index to 42 athletes. Based on ROC analysis, the following parameters were included in the score: indexed right/left atrial volumes ratio (RAVI/LAVI ratio), NT-proBNP, RVOT measurements (PLAX and PSAX BSA-corrected), tricuspid annular motion (TAM), precordial TWI and depolarization abnormalities according to TFC. Results: ARVC patients had a higher RAVI/LAVI ratio (1.76 ± 1.5 vs. 0.87 ± 0.2, p < 0.001), lower right ventricular function (fac: 29 ± 10.1 vs. 42.2 ± 5%, p < 0.001; TAM: 19.8 ± 5.4 vs. 23.8 ± 3.8 mm, p = 0.001) and higher serum NT-proBNP levels (345 ± 612 vs. 48 ± 57 ng/L, p < 0.001). Our score showed a good performance, which is comparable to the 2010 TFC using those parameters, which are available in routine clinical practice (AUC93%, p < 0.001 (95%CI 0.874–0.995) vs. AUC97%, p < 0.001 (95%CI 0.93–1.00). A score of 6/12 points yielded a specificity of 91% and an improved sensitivity of 67% for ARVC diagnosis as compared to a sensitivity of 41% for the abovementioned readily available 2010 TFC. Conclusions: ARVC patients present with significantly larger RA compared to athletes, resulting in a greater RAVI/LAVI ratio. Our novel diagnostic score includes readily available clinical parameters and has a high diagnostic accuracy to differentiate between ARVC and the athlete’s heart.
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14
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Gasperetti A, Dello Russo A, Busana M, Dessanai M, Pizzamiglio F, Saguner AM, te Riele AS, Sommariva E, Vettor G, Bosman L, Duru F, Zeppilli P, Di Biase L, Natale A, Tondo C, Casella M. Novel risk calculator performance in athletes with arrhythmogenic right ventricular cardiomyopathy. Heart Rhythm 2020; 17:1251-1259. [DOI: 10.1016/j.hrthm.2020.03.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 03/06/2020] [Indexed: 12/17/2022]
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15
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Zorzi A, Vio R, Bettella N, Corrado D. Criteria for interpretation of the athlete's ECG: A critical appraisal. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:882-890. [PMID: 32602144 DOI: 10.1111/pace.14001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/18/2020] [Accepted: 06/28/2020] [Indexed: 01/27/2023]
Abstract
The electrocardiogram (ECG) is cheap and widely available but its use as a screening tool for early identification of athletes with a cardiac disease at risk of sudden cardiac death is controversial because of presumed low specificity. In the last decade, several efforts have been made to improve the distinction between physiological and pathological ECG findings in the athlete, leading to continuous evolution of the interpretation criteria. The most recent 2017 International criteria grouped ECG changes into three categories: normal, borderline, and abnormal. Borderline findings warrant further investigations only when two or more are present while abnormal changes should always be considered as the sign of a possible underlying disease. This review encompasses the evolution of the athlete's ECG interpretation criteria and highlights areas of uncertainty that will need to be addressed by further studies.
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Affiliation(s)
- Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Riccardo Vio
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Natascia Bettella
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
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16
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Mascia G, Arbelo E, Porto I, Brugada R, Brugada J. The arrhythmogenic right ventricular cardiomyopathy in comparison to the athletic heart. J Cardiovasc Electrophysiol 2020; 31:1836-1843. [PMID: 32367567 DOI: 10.1111/jce.14526] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/25/2020] [Accepted: 04/24/2020] [Indexed: 01/02/2023]
Abstract
Intense exercise-induced right ventricular remodeling is a potential adaptation of cardiac function and structure. The features of the remodeling may overlap with those of a very early form of arrhythmogenic right ventricular cardiomyopathy (ARVC): at this early stage, it could be difficult to discriminate ARVC, from exercise-induced cardiac adaptation that may develop in normal individuals. The purpose of this paper is to discuss which exercise-induced remodeling may be a pathological or a physiological finding. A complete evaluation may be required to identify the pathological features of ARVC that would include potential risk of sudden cardiac death during sport or, to avoid the false diagnosis of ARVC. The most recent expert assessment of arrhythmogenic cardiomyopathy focuses on endurance athletes presenting with clinical features indistinguishable from ARVC.
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Affiliation(s)
- Giuseppe Mascia
- Department of Internal Medicine (DIMI) Clinic of Cardiovascular Diseases, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Italian IRCCS Cardiovascular Network, Genoa, Italy.,Cardiology and Electrophysiology Unit, Department of Internal Medicine, Azienda USL Toscana Centro, Florence, Italy
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Institut d'Investigaciò August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Italo Porto
- Department of Internal Medicine (DIMI) Clinic of Cardiovascular Diseases, University of Genoa, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Italian IRCCS Cardiovascular Network, Genoa, Italy
| | - Ramon Brugada
- Cardiovascular Genetics Center, Institut d'Investigació Biomèdica Girona (IDIBGI), University of Girona, Girona, Spain
| | - Josep Brugada
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Institut d'Investigaciò August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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17
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D'Ascenzi F, Anselmi F, Adami PE, Pelliccia A. Interpretation of T-wave inversion in physiological and pathological conditions: Current state and future perspectives. Clin Cardiol 2020; 43:827-833. [PMID: 32259342 PMCID: PMC7403675 DOI: 10.1002/clc.23365] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 03/16/2020] [Accepted: 03/24/2020] [Indexed: 12/20/2022] Open
Abstract
The presence of T‐wave inversion (TWI) at 12‐lead electrocardiogram (ECG) in competitive athletes is one of the major diagnostic challenges for sports physicians and consulting cardiologists. Indeed, while the presence of TWI may be associated with some benign conditions and it may be occasionally seen in healthy athletes presenting signs of cardiac remodeling, it may also represent an early sign of an underlying, concealed structural heart disease or life‐threatening arrhythmogenic cardiomyopathies, which may be responsible for exercise‐related sudden cardiac death (SCD). The interpretation of TWI in athletes is complex and the inherent implications for the clinical practice represent a conundrum for physicians. Accordingly, the detection of TWI should be viewed as a potential red flag on the ECG of young and apparently healthy athletes and warrants further investigations because it may represent the initial expression of cardiomyopathies that may not be evident until many years later and that may ultimately be associated with adverse outcomes. The aim of this review is, therefore, to report an update of the literature on TWI in athletes, with a specific focus on the interpretation and management.
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Affiliation(s)
- Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesca Anselmi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Paolo Emilio Adami
- Health and Science Department, World Athletics, Monaco, Monaco.,Department of Exercise, Human and Health Sciences, Foro Italico University of Rome, Rome, Italy
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