A new consensus document on electrocardiographic interpretation in athletes: does it help to prevent sudden cardiac death in athletes?

Netherlands Heart Journal, Feb 2018

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.

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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)


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N. M. Panhuyzen-Goedkoop, H. T. Jørstad, J. L. R. M. Smeets. A new consensus document on electrocardiographic interpretation in athletes: does it help to prevent sudden cardiac death in athletes?, Netherlands Heart Journal, 2018, pp. 127-132, Volume 26, Issue 3, DOI: 10.1007/s12471-018-1076-6