V1 and a qR complex in lead V1. The presence of RHV pattern on ECG should prompt further investigation in the athlete. Right axis deviation Right-axis deviation is defined as a frontal plane QRS axis of >120° (figure 20). Right atrial enlargement Right atrial enlargement is defined as a P wave greater than or equal to 2.5 mm in leads II, III and aVF (figure 20). RV strain Right ventricular ‘strain’ is defined as ST depression and TWI in the right precordial leads (V1–V3) (figure 20). As with LVH, these ST-T changes are referred to as ‘secondary ST-T abnormalities.’ Evaluation of suspected pulmonary hypertension Evaluation should include clinical assessment with appropriate diagnostic testing. Pulmonary artery pressures often can be assessed by Doppler echocardiography, and both echocardiography and cardiac MRI can evaluate RVH and function, and assess for secondary causes of PHT such as intracardiac shunts. Definitive diagnosis of PHT is made by cardiac catheterisation. Conclusions The cardiomyopathies are a heterogeneous group of heart muscle diseases associated with important clinical implications. In aggregate, HCM, ARVC, DCM and LVNC underlie the majority of autopsy-positive sudden death cases in young athletes. Each of these cardiomyopathies can manifest in athletes with a broad spectrum of clinical severity ranging from completely asymptomatic to markedly symptomatic disease with associated exercise limitations. The ECG plays an important role in the cardiovascular assessment of athletes given its capacity to detect cardiomyopathies. As delineated in this paper, there is a concise list of ECG findings that may indicate the presence of an underlying cardiomyopathic condition. Importantly, these ECG findings are not characteristic of the benign exercise-induced cardiac remodelling common in athletes, and, thus, the ECG can be useful for differentiating physiological cardiac enlargement in athletes from pathological myocardial disease. Clinicians charged with the cardiovascular care of athletes should be familiar with the ECG findings associated with cardiomyopathy. During pre-participation screening that includes the use of ECG, asymptomatic athletes with any of these abnormal findings should undergo further testing. Athletes presenting with symptoms that may be indicative of an underlying cardiomyopathy (ie, exercise intolerance, inappropriate exertional dyspnoea, chest pain, palpitations or syncope) should undergo a prompt evaluation including an ECG. The symptomatic athlete with an ECG suggestive of a cardiomyopathy requires a comprehensive and definitive assessment that will include some combination of noninvasive cardiac imaging, exercise testing and ambulatory rhythm monitoring. This evaluation should be conducted by a sports medicine team that includes a cardiovascular specialist familiar with cardiomyopathic diseases and with experience in caring for athletes. Additional resources For a free online training module on ECG interpretation in athletes, please visit:http://learning.bmj.com/ECGathlete. For the November 2012 BJSM supplement on ‘Advances in Sports Cardiology’, please visit:http://bjsm.bmj.com/content/46/Suppl_1.toc. Autor affiliations Competing interests None. Provenance and peer review Commissioned; internally peer reviewed. References 44 Basso C, Corrado D, Marcus FI, et al. Arrhythmogenic right ventricular cardiomyopathy. Lancet 2009;373:1289–300. 45 Corrado D, Basso C, Thiene G. Arrhythmogenic right ventricular cardiomyopathy: an update. Heart 2009;95:766–73. 46 Heidbuchel H, Hoogsteen J, Fagard R, et al. High prevalence of right ventricular involvement in endurance athletes with ventricular arrhythmias. Role of an electrophysiologic study in risk stratification. Eur Heart J 2003;24:1473–80. 47 La Gerche A, Robberecht C, Kuiperi C, et al. Lower than expected desmosomal gene mutation prevalence in endurance athletes with complex ventricular arrhythmias of right ventricular origin. Heart 2010;96:1268–74. 48 Heidbuchel H, Prior DL, Gerche AL. Ventricular arrhythmias associated with long-term endurance sports: what is the evidence? Br J Sports Med 2012;46(Suppl 1):i44–50. 49 Marcus FI, McKenna WJ, Sherrill D, et al. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria. Circulation 2010;121:1533–41. nummer 4 | september 2013 | Sport & Geneeskunde 37 Pagina 36
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