criteria tool to guide ECG interpretation significantly improved accuracy to distinguish normal from abnormal findings, even in physicians with little or no experience.10 Therefore, physician education in ECG interpretation is feasible and accompanied by meaningful improvements in accuracy when a reference standard is used to assist interpretation. Further education is needed to produce a larger physician infrastructure that is skilled and capable of accurate ECG interpretation in athletes. Summit on ECG interpretation in athletes On 13–14 February 2012, the American Medical Society for Sports Medicine (AMSSM) co-sponsored by the FIFA Medical Assessment and Research Center (F-MARC) held a ‘Summit on Electrocardiogram Interpretation in Athletes’ in Seattle, Washington. Partnering medical societies included the European Society of Cardiology (ESC) Sports Cardiology Subsection and the Pediatric & Congenital Electrophysiology Society (PACES), as well as other leading cardiologists on ECG interpretation in athletes from the USA, Europe and around the world. The goals of the summit meeting were to: 1. define ECG interpretation standards to help physicians distinguish normal ECG alterations in athletes from abnormal ECG findings that require additional evaluation for conditions associated with SCD; 2. outline recommendations for the initial evaluation of ECG abnormalities suggestive of a pathological cardiovascular disorder; and 3. assemble this information into a comprehensive resource and online training course targeted for physicians around the world to gain expertise and competence in ECG interpretation. The consensus recommendations developed are presented in three papers: 4. Normal Electrocardiographic Findings: Recognizing Physiologic Adaptations in Athletes11 5. Abnormal Electrocardiographic Findings in Athletes: Recognizing Changes Suggestive of Cardiomyopathy12 6. Abnormal Electrocardiographic Findings in Athletes: Recognizing Changes Suggestive of Primary Electrical Disease13 Box 1 summarises a list of normal ECG findings in athletes that are considered physiological adaptations to regular exercise and do not require further evaluation. Table 1 summarises a list of abnormal ECG findings unrelated to athletic training that may suggest the presence of a pathological cardiac disorder and should trigger additional evaluation in an athlete. Box 1 Normal ECG findings in athletes 1. Sinus bradycardia (≥ 30 bpm) 2. Sinus arrhythmia 3. Ectopic atrial rhythm 4. Junctional escape rhythm 5. 1° AV block (PR interval > 200 ms) 6. Mobitz Type I (Wenckebach) 2° AV block 7. Incomplete RBBB 8. Isolated QRS voltage criteria for LVH  Except: QRS voltage criteria for LVH occurring with any non-voltage criteria for LVH such as left atrial enlargement, left axis deviation, ST segment depression, T-wave inversion or pathological Q waves 9. Early repolarisation (ST elevation, J-point elevation, J-waves or terminal QRS slurring) 10. Convex (‘domed’) ST segment elevation combined with T-wave inversion in leads V1–V4 in black/African athletes These common training-related ECG alterations are physiological adaptations to regular exercise, considered normal variants in athletes and do not require further evaluation in asymptomatic athletes. AV, atrioventricular; bpm, beats per minute; LVH, left ventricular hypertrophy; ms, milliseconds; RBBB, right bundle branch block. Online e-learning ECG training module—free! The Seattle Criteria will be used to develop a comprehensive online training module for physicians to acquire a common foundation in ECG interpretation in athletes. This state of the art E-learning resource provides additional ECG examples, figures and explanations, and is prepared in a user friendly educational format to optimise learning. This online training module is accessible at no cost to any physician world-wide at: http://learning.bmj.com/ECGathlete Limitations of the Seattle criteria While the ECG increases the ability to detect underlying cardiovascular conditions that place athletes at increased risk, ECG as a diagnostic tool has limitations in both sensitivity and specificity. Even if properly interpreted, an ECG will not detect all conditions predisposing to SCD. In addition, the true prevalence of specific ECG parameters in athletes and in diseases that predispose to SCD is often unknown and requires further study. The Seattle Criteria were developed with thoughtful attention to balance sensitivity (disease detection) and specificity (falsepositives), while maintaining a clear and usable nummer 1 | maart 2013 | Sport & Geneeskunde 23 Pagina 22

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