302 T-wave inversions in Adolescent Athletes electrocardiograms: Prevalence and significance?
JC Rawlins1; M Papadakis1; C Edwards1; S Gati2; S Basavarajaiah3; S Sharma3
1King's College Hospital Cardiology, London, United Kingdom
2Queen Elizabeth Hospital Cardiology, London, United Kingdom
3University Hospital, Lewisham Cardiology, London, United Kingdom
Purpose: Participation in intense physical activity is associated with the development of deep T wave inversions in the ECG of some adult athletes, similar to those observed in hypertrophic cardiomyopathy (HCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC). The prevalence and significance of such T wave inversions in adolescent athletes is unknown, however this cohort is most vulnerable to exercise related sudden death from HCM and ARVC. We aimed to characterise the prevalence and significance of T-wave inversions in adolescent athletes.
Methods: Between 1996 and 2007, 1653 adolescent highly trained athlete's (83% male) aged 14–18 years and 400 healthy controls of similar age, size, and gender underwent 12 – lead ECG and trans-thoracic echocardiography. Athletes and controls exhibiting T-wave inversions in leads other than V1, AVR, isolated III or isolated AVL, underwent further investigations with exercise stress testing, ambulatory 24hr ECG recording and cardiac magnetic resonance scanning looking specifically for features of HCM and ARVC.
Results: There was no significant difference in the overall prevalence of T-wave inversions between athletes and controls (4% v.s. 3%). T-wave inversions in leads V1-V3 were almost all confined to athletes (96%) and controls (96%) aged >16 years. Only 0.2% of athletes aged>16 years exhibited T-wave inversions in the precordial leads beyond V2. T-wave inversions were present in the inferior and/or lateral leads in 17 (1%) athletes overall, and were associated with a high prevalence (56%) of physiological left ventricular hypertrophy (defined as LVH>144 mm associated with an enlarged left ventricular cavity and normal diastolic function) or congenital heart defects.
Deep T wave inversions (>0.2mV) were absent in non athletes, and present in only 0.2% of all athletes evaluated. We did not diagnose HCM or ARVC definitively in any individuals despite intense investigations.
Conclusion: Wave inversions in the right pre-cordial leads (V1-V2) are relatively common in adolescent athletes>16 years and probably represent the juvenile ECG pattern in asymptomatic athletes without a family history of cardiomyopathy. T-wave inversions beyond V2 in athletes> 16 years and deep Twave inversions in any adolescent athlete are exceptionally rare and warrant further investigation. T wave inversions in the inferior/lateral leads are relatively rare, but are commonly associated with LVH or congenital anomalies and therefore require further evaluation to exclude a potential cause of sudden cardiac death.
303 Should exercise electrocardiogram be included in prepartecipation screening of competitive athletes? The 5-year experience of the Institute of Sports Medicine in Italy
F Sofi1; A Capalbo2; N Pucci1; P Bernardo1; J Giuliattini1; F Alessandri1; F Condino1; R Abbate2; GF Gensini3; S Califano2
1University of Florence Medical and Surgical Critical Care, Florence, Italy
2Institute of Sports Medicine, Florence, Italy
3Don Carlo Gnocchi Foundation Onlus IRCCS, Florence, Italy
Purpose: Preparticipation cardiovascular screening of competitive athletes is still a matter of dispute among clinicians. Recently, the role of such cardiovascular screening for preventing sudden cardiac deaths has been reported, but its implementation as a routine examination for competitive athletes is debated. In particular, the inclusion of tests such as basal and exercise electrocardiograms (ECGs) in the prepartecipation screening programme, still remains. Aim of the present study is to report the 5-year experience of the Institute of Sports Medicine, Italy, in order to evaluate the efficacy of cardiovascular screening examinations in identifying athletes at high risk of cardiovascular abnormalities.
Methods: During a 5-year period (2002–2006), 33,748 competitive athletes (77.5% males) who referred consecutively to the Institute of Sports Medicine to obtain the clinical eligibility for competitions were evaluated. All the athletes were examined by following the protocol for preparticipation screening that included family and personal medical history, physical examination, blood pressure measurement, basal and exercise 12-lead ECGs.
Results: The median age of the study population was 27.6 years (range: 5–85) with a consistent proportion (30.2%) of subjects older than 40 years. The study population participated in over than 30 different sports, with soccer and volleyball representing the first type of sport practiced by males and females, respectively. An altered blood pressure profile was demonstrated in 5,682 (16.8%) subjects. The basal 12-lead ECG patterns were considered abnormal in 2,127 (6.3%) subjects, with the most frequent abnormalities that included mostly innocent ECG changes among athletes such as marked sinus bradycardia (979, 2.9%), incomplete right bundle branch block (371, 1.1%), and early ripolarization pattern (236, 0.7%). On the other hand, exercise ECG reported an abnormal pattern in 1,465 (4.3%) subjects with a significant prevalence of ventricular and supraventricular arrhythmias (873, 2.6% and 498, 1.5%, respectively) and of STsegment alterations (54, 0.2%). At the end of the medical examinations, 196 (0.6%) athletes were disqualified from competition, and for 1,269 additional cardiovascular testing was required.
Conclusion: Preparticipation screening program including basal and exercise ECGs seems to represent an effective preventive measure for identifying high-risk young and middle-aged athletes.
304 Repolarization patterns in French top level male athletes and relationships with echocardiographic data
A Gehanne1; N Ville2; G Kervio2; J Gueneron3; F Carre3
1Departement Maladies Coeur et Vaisseaux CCP-CHU Pontchaillou, Rennes, France
2INSERM, U642, Rennes, France
3INSEP, Paris, France
Athletes' sudden death mostly originates from cardiac disease. Major questions arising from the preparticipation screening ECG are relative to ventricular repolarization disturbances and QT interval duration.
Purposes: (i) to describe cardiac repolarization peculiarities and the distribution of QT interval duration in French elite athletes regarding to the sport discipline, (ii) to study the relationships between electrocardiographic and echocardiographic patterns.
Methods: 799 French male clinically healthy top-level athletes have completed this multi-centric retrospective study. Their sport disciplines were classified as endurance, strength or intermediate's ones in regards to the dominant bioenergetic component. Resting 12-lead ECG and usual resting echocardiography have been performed. Heart rate (HR), RR and QT interval durations, Bazett corrected QT duration (QTc), and major repolarisation peculiarities (MRP) were analyzed.
Results: RR duration was higher in endurance group (p>0.05). Few MRP have been observed (8% of athletes, n=62): deeply inverted T-waves in 2 leads (7.5%), depressed ST-segment (0.3%). The lowest prevalence of MRP has been noted in strength athletes (2.4%) and the highest in intermediate ones (11.9%). QT values were higher in endurance than in both other groups (p>0.01). Twelve athletes (1.5%) showed a QTc>440 ms. QTc did not significantly differ regarding to the dominant bioenergetic component. Nevertheless, for a similar resting HR, QT duration was lower in strength than in both other groups (p>0.05). A significant linear relationship has been noted between QT and RR duration (r=0.74, p>0.05), with two distinct regression slopes when separating athletes with and without resting bradycardia (p>0.001). When HR was divided in 4 classes (>80, [60–80], [40-60], >40 beat/min), QTc values significantly differed from one to another (p>0.01). Athletes with indexed left ventricular mass <111 g/m show more MRP (2=4.7, p>0.05). Athletes with MRP showed longer QT values and end-diastolic parietal wall thickness than the others athletes (p>0.05). Whatever the dominant bioenergetic component group, QT and QTc were poorly correlated with echocardiographic data (r less than 0.25).
Conclusion: Major ECG peculiarities are rare in French clinically healthy top-level athletes and mainly observed in bioenergetic intermediate sports and in athletes with cardiac hypertrophy. QT duration is longer in endurance athletes however poorly influenced by cardiac remodeling. Because of QT duration underestimation, QTc must be precociously interpreted in athletes with sinus bradycardia.
305 Evaluation of structural damage of the myocardium by magnetic resonance imaging after marathon running in nonelite athletes with biochemical evidence of cardiac injury
H Hanssen1; A Keithahn2; G Hertel2; V Drexel2; A Beer1; A Schmidt-Trucksaess1; M Schwaiger1; M Halle2
1Department of Prevention and Sports Medicine, TUM Technical University Munich (TUM), Munich, Germany
2Department of Nuclear Medicine, TUM Technical University Munich (TUM), Munich, Germany
Background: Marathon running has been shown to evolve in myocardial injury and ventricular dysfunction. The biochemical evidence of cardiac injury is based on elevated levels of troponin T (cTNT) and N-terminal pro-brain natriuretic peptide (NT-proBNP). Echocardiographic evidence is suggestive of ventricular dysfunction following marathon stress. Presumptive structural damage to the myocardium after marathon running remains to be elucidated by means of Cardiac Magnetic Resonance (CMR) imaging.
Study design and Methods: Twelve nonelite male marathon runners (43±5 years) were examined by means of CMR using myocardial late enhancement (LE) before and after a marathon. Marathon events were organized to ensure CMR imaging immediately after cessation of the marathon. Blood samples for measurement of cTNT and NT-proBNP (third generation) were taken before and immediately after the marathon. CMR imaging was performed on a 1,5T MR device applying gadolinium based contrast medium at a concentration of 0,222 mmol/kg body weight. Images were acquired 12±2 min after injection of the contrast medium. The LE protocol was performed using two standard long axis views and one short axis view in order to cover the entire heart. All MRI scans were interpreted visually by two independent experienced investigators by consensus. All data sets for the assessment of LE were classified according to the 17 Segment Model of the American Heart Association. Statistical analysis was conducted using a paired Student's t-test.
Results: All cTNT concentrations were ≤0.0033 ng/mL at baseline. The mean cTNT value was 0,015±0.0144 ng/mL (p=0.004 for difference from before the marathon) with a post-race range from ≤0.003 to 0.044 ng/mL (>0.011 ng/mL in 58% and ≤0.033 ng/ml in 25% of cases). NT-proBNP concentrations increased during the marathon from 25±16 pg/mL to 138±62 pg/mL (p>0,001;>88 pg/mL in 75% and>200 pg/mL in 25% of cases). All athletes underwent CMR imaging within one hour after cessation of the marathon. Myocardial LE showed no contrast medium absorption indicative of structural myocardial damage in any of the participants.
Conclusion: Our results confirm an increase of biochemical markers during a marathon. However, we found no correlation between biochemically evidenced cardiac injury and signs of structural damage of the myocardium by CMR imaging. Therefore, significant damage of the myocardium induced by marathon running can be excluded. Whether increased levels of cardiac enzymes may be caused by diffuse myocardial microtrauma remains to be shown.
306 Evaluation of “athletic” cardiac hypertrophy: Electrocardiogram vs echocardiogram
E Dimitros; N Koutlianos; E Kouidi; A Deligiannis
Sports Medicine Laboratory Physical Education and Sports Science, Thessaloniki, Greece
The identification of left ventricular hypertrophy (LVH) through electrocardiographic (ECG) voltage criteria has been widely studied in patients. However, the validity of these criteria in “athlete's heart” remains quite unclear.
Purpose: The evaluation of the most common ECG parameters indicative of LVH in comparison with the known echocardiographic ones in 300 amateur athletes (aged 19.3±5.6 years).
Methods: The study group comprised 100 athletes performing static, 100 dynamic and 100 mixed type training. Additionally, 100 sedentary healthy subjects were used as controls (aged 19.6±6.4 years). Thirteen electrocardiographic voltage criteria (Sokolow-Lyon, Cornell, Cornell product, 12-lead product, Gubner and Ungerleider, Minnesota Code, e.t.c.) indicative of LVH were calculated from resting 12-lead ECG and correlated with the echocardiographic indices LVMI and EDVI.
Results: Athletes participating in mixed type sports, presented the highest values of all voltage criteria compared to the other groups (p>0.05). Furthermore, ANCOVA analysis showed that the Sokolow-Lyon index was affected by the type of exercise (8.9%), the age (4.3%) and the body mass index (3.3%) in total variance of 18.7% (p>0.05). A major finding of this study was the absence of significant correlation between any ECG voltage criterion and both echocardiographic indices. However, the Cornell index and the sum of 12-leads QRS voltage both multiplied by QRS duration, were statistically found to be the most relatively valid criteria for the electrocardiographic detection of LVH in athletes (Cornell product vs LVMI, r=0.20, p>0.05 and vs EDVI, r=0.27, p>0.05; 12-lead poduct vs LVMI, r=0.20, p>0.05 and vs EDVI, r=0.20, p>0.05).
Conclusion: The voltage indices of ECG should not be considered valid when assessing “athletic” cardiac hypertrophy. On the other side, echocardiographic study is preferable to evaluate exercise-induced cardiac adaptations or to distinguish physiologic from pathologic LVH.
