This document was developed in collaboration between the American Medical Society for Sports Medicine (AMSSM), the Section on Sports Cardiology of the European Association for Cardiovascular Prevention and Rehabilitation (EACPR), a registered branch of the European Society of Cardiology (ESC), the FIFA Medical Assessment and Research Center (F-MARC), and the Pediatric & Congenital Electrophysiology Society (PACES). Drezner JA, Ashley E, Baggish AL, et al. Br J Sports Med 2013;47: 137–152. Abstract Cardiomyopathies are a heterogeneous group of heart muscle diseases and collectively are the leading cause of sudden cardiac death (SCD) in young athletes. The 12-lead ECG is utilised as both a screening and diagnostic tool for detecting conditions associated with SCD. Fundamental to the appropriate evaluation of athletes undergoing ECG is an understanding of the ECG findings that may indicate the presence of an underlying pathological cardiac disorder. This article describes ECG findings present in cardiomyopathies afflicting young athletes and outlines appropriate steps for further evaluation of these ECG abnormalities. The ECG findings defined as abnormal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine. Introduction The cardiomyopathies are a diverse group of heart muscle diseases that are defined and subdivided in clinical practice by different structural and functional characteristics. As a family of related diseases, the cardiomyopathies are the leading cause of sudden cardiac death (SCD) in young competitive athletes.1–3 Athletes with an underlying cardiomyopathy may present with disease-related symptoms or may be asymptomatic and thus only identified by abnormal testing during pre-participation screening. Although a definitive diagnosis may require extensive evaluation by a cardiovascular specialist, the 12-lead ECG is commonly abnormal among athletes with an underlying cardiomyopathy. Therefore, it is of paramount importance that clinicians responsible for ECG interpretation in athletes be familiar with key findings associated with underlying diseases of the heart muscle. This paper will review the principal ECG findings associated with the most common forms of cardiomyopathy relevant to the care of the young athlete. Initial testing for further evaluation of abnormal ECG findings is also presented. Distinguishing normal from abnormal A challenge in the use of ECG for screening or diagnostic evaluations in athletes is the ability to accurately differentiate findings suggestive of a potentially lethal cardiovascular disorder from benign physiological adaptations occurring as the result of regular and sustained intensive training (ie, athlete’s heart). Several reports have outlined ECG criteria intended to distinguish normal ECG findings in athletes from ECG abnormalities requiring additional evaluation.4–9 On 13–14 February 2012, an international group of experts in sports cardiology and sports medicine convened in Seattle, Washington, to define contemporary standards for ECG interpretation in athletes. The objective of the meeting was to help physicians distinguish normal ECG alterations in athletes from abnormal ECG findings that require additional evaluation for conditions that predispose to SCD.10 is presented separately.11 A review of normal ECG findings in athletes In this paper, abnormal ECG findings are presented relative to the most common cardiomyopathies associated with SCD in athletes: hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), dilated cardiomyopathy (DCM) and left-ventricular non-compaction (LVNC). Table 1 summarises a list of abnormal ECG findings unrelated to athletic training that may suggest the presence of an underlying cardiomyopathy and should trigger additional evaluation in an athlete. Hypertrophic cardiomyopathy HCM is a genetic disease of the heart muscle. It is characterised by ventricular hypertrophy in the absence of a recognisable cause such as aortic valve disease or hypertension. A common pattern of hypertrophy in HCM is an asymmetric septal hypertrophy where the interventricular septum is thicker than the rest of the left ventricle. However, many nummer 3 | juli 2013 | Sport & Geneeskunde 27 Pagina 26
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