A new consensus document on electrocardiographic interpretation in athletes: does it help to prevent sudden cardiac death in athletes?
Neth Heart J
A new consensus document on electrocardiographic interpretation in athletes: does it help to prevent sudden cardiac death in athletes?
N. M. Panhuyzen-Goedkoop 0 1
H. T. Jørstad 0 1
J. L. R. M. Smeets 0 1
0 Radboud University Medical Centre , Radboudumc, Nijmegen , The Netherlands
1 Academical Medical Centre Amsterdam , Amsterdam , The Netherlands
Sudden cardiac arrest or death (SCA/SCD) in athletes has a low event rate. Pre-participation or eligibility screening is a widely accepted method of primary prevention of SCA/SCD in athletes. Most European countries and international sports governing bodies perform ECG-inclusive screening. However, implementation of a resting 12-lead ECG in pre-participation or eligibility cardiac screening is still a topic of debate. Recently, the 'International recommendations for electrocardiographic interpretation in athletes' was published in three leading international medical journals. These international ECG criteria are based on studies with detailed information on resting 12-lead ECG of Caucasian and Afro-Caribbean athletes or on consensus in case evidence was lacking. Normal, borderline and abnormal ECG findings in young athletes (age 12-35 years) are clearly described and illustrated to assist the screening physician in interpreting ECGs of athletes correctly. In this 'point of view paper' we will discuss whether these new ECG criteria actually help prevent SCA/SCD in athletes.
Athlete; ECG; Sudden cardiac death; Pre-participation screening; Prevention
Introduction
Sudden cardiac arrest and/or death (SCA/SCD) in athletes
is a very tragic event that attracts a lot of media attention.
The key question conventionally raised after such an event
resulting from lethal ventricular arrhythmia, i. e. ventricular
tachycardia/fibrillation (VT/VF), is: could this have been
prevented? SCD in competitive athletes aged 35 years and
younger (young athletes) is rare (0.6–2.85/100,000
annually). The incidence is considerably lower than in the
overall population (3–10.7/100,000 annually) and significantly
lower than the incidence of VT/VF in Europe (84.0/100,000
annually) [
1–7
]. Most inherited and congenital
cardiovascular diseases (CVD) in athletes at risk of VT/VF can
be identified during life [
2, 3
]. To date, primary
prevention with pre-participation or eligibility cardiac screening is
a widely accepted method to reduce SCA/SCD in athletes
[
8–10
]. If pre-participation or eligibility cardiac screening
fails to identify athletes at risk, secondary prevention with
bystander resuscitation, including defibrillation with
automatic external defibrillator (AED), is essential to save an
athlete’s life [11]. However, an AED is no adequate
replacement for pre-participation or eligibility cardiac screening
[
11
]. How we need to screen athletes for conditions
predisposing to VT/VF optimally is a topic of debate.
In this manuscript we discuss the ‘International
recommendations for electrocardiographic interpretation in
athletes’, questioning if these new ECG criteria help
preventing SCA/SCD in athletes [
12–14
].
Pre-participation cardiac screening
The purpose of pre-participation or eligibility cardiac
screening in athletes is identifying CVD at risk of VT/VF
and reducing SCA/SCD by disease management [
8–10
].
Pre-participation or eligibility cardiac screening consists of
personal and family history taking and physical
examination [
1, 8–10, 15
]. Pre-participation or eligibility cardiac
screening performed by most European countries and
international sports governing bodies include a 12-lead resting
ECG [
1, 8, 16
]. In the Netherlands, pre-participation or
eligibility cardiac screening is performed by sports
physicians according to the ‘Lausanne protocol’ [
15
]. If
pre
Refined criteria
Caucasian
FPR (%)
6.1
2.5
2.1
Afro/
Caribbean
FPR (%)
15.8
3.1
9.2
Borderline ECG finding
Complete RBBB
Left atrial enlargement
Right atrial enlargement
Left axis deviation
Right axis deviation
ESC European Society of Cardiology, FPR false positive rate
AV atrioventricular, ECG electrocardiogram, RBBB right bundle branch block, LVH left ventricular hypertrophy, RVH right ventricular
hypertrophy
participation or eligibility cardiac screening results raise
suspicion of a CVD at risk of VT/VF additional cardiac
evaluation is recommended before clearing the athlete [
8, 9,
17
]. To adequately perform pre-participation or eligibility
cardiac screening, the screening physician needs training
and skills in physiology, ECG interpretation, CVD at risk
of VT/VF, and CVD management in athletes [
10, 18
].
Athlete ECG
In 2010, the European Society of Cardiology (ESC) for
the first time classified athlete ECGs in training-related and
training-unrelated or pathologic ECG findings [
16
].
Training-related ECG findings induced by vagotonia and
volume and/or pressure overload of the cardiac cavities are
an expression of athlete’s physiologic cardiac adaptation
or remodelli (...truncated)