ESC REPORT Recommendations for interpretation of 12-lead electrocardiogram in t

ESC REPORT Recommendations for interpretation of 12-lead electrocardiogram in the athlete Domenico Corrado1*, Antonio Pelliccia2, Hein Heidbuchel3, Sanjay Sharma4, Mark Link5, Cristina Basso6, Alessandro Biffi2, Gianfranco Buja1, Pietro Delise7, Ihor Gussac8, Aris Anastasakis9, Mats Borjesson10, Hans Halvor Bjørnstad11, Franc ¸ois Carre ` 12, Asterios Deligiannis13, Dorian Dugmore14, Robert Fagard3, Jan Hoogsteen15, Klaus P. Mellwig16, Nicole Panhuyzen-Goedkoop17, Erik Solberg18, Luc Vanhees3, Jonathan Drezner19, N.A. Mark Estes, III5, Sabino Iliceto1, Barry J. Maron20, Roberto Peidro21, Peter J. Schwartz22, Ricardo Stein23, Gaetano Thiene6, Paolo Zeppilli24, and William J. McKenna25 on behalf of the Sections of Sports Cardiology of the European Association of Cardiovascular Prevention and Rehabilitation; and the Working Group of Myocardial and Pericardial Disease of the European Society of Cardiology 1Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Via Giustiniani,2, Padova 35121, Italy; 2Institute for Sports Sciences, Rome, Italy; 3Cardiovascular Rehabilitation Unit, KU Leuven, Leuven, Belgium; 4King’s College Hospital, London, UK; 5New England Medical Center, Boston, MA, USA; 6Department of Medical- Diagnostic Sciences, University of Padua, Padua, Italy; 7Civil Hospital, Conegliano, Italy; 8University of Medicine and Dentistry, RWJ Medical School, New Brunswick, NJ, USA; 9Division of Inherited Cardiovascular Diseases, University of Athens, Greece; 10Department of Medicine, Sahlgrens University Hospital/O ¨ stra, Gothenburg, Sweden; 11Department Heart Disease, Haukeland University Hospital, Bergen, Norway; 12Sport Medicine, University of Rennes, Rennes, France; 13Sports Medicine, Aristotle University, Thessaloniki, Greece; 14Wellness Medical Center, Stockport, UK; 15Department of Cardiology, Maxima Medical Centre, Veldhoven, Netherlands; 16Heart Center NRW, University Hospital, Bad Oeynhausen, Germany; 17Department Cardiology, Nijmegen, The Netherlands; 18Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway; 19Department of Family Medicine, University of Washington, Seattle, WA, USA; 20Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN, USA; 21Favaloro Foundation, Buenos Aires, Argentina; 22Department of Cardiology, Fondazione IRCCS Policlinico, San Matteo, Pavia; 23Exercise Pathophysiology Research Laboratory, Hospital de Clinicas Porto Alegre, Porto Alegre, Brazil; 24Sports Medicine Department, Institute of Internal Medicine and Geriatrics, Catholic University of Sacred Heart, Rome, Italy; and 25The Heart Hospital, University College of London, London, UK Received 20 July 2009; revised 22 September 2009; accepted 4 October 2009; online publish-ahead-of-print 20 November 2009 Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical phys- icians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and manage- ment of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular con- dition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Keywords Athlete’s heart † Cardiomyopathy † Electrocardiogram † Ion-channel disease † Sudden death † Ventricular fibrillation † Ventricular tachycardia * Corresponding author. Tel: þ39 49 821 2458, Fax: þ39 49 821 2309, Email: domenico.corrado@unipd.it Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org. European Heart Journal (2010) 31, 243–259 doi:10.1093/eurheartj/ehp473 by guest on June 15, 2016 http://eurheartj.oxfordjournals.org/ Downloaded from Introduction Regular sports participation is encouraged by the medical commu- nity as part of cardiovascular prevention measures, because it improves fitness and reduces cardiovascular morbidity and mor- tality worldwide.1,2 A large proportion of the young population participates in competitive or recreational sports activity. The 12-lead electrocardiogram (ECG) is an established tool in the evaluation of athletes, providing important diagnostic and prognos- tic information on a variety of cardiovascular diseases which are associated with an increased risk of sudden cardiac death (SCD) during sports. Physicians are frequently asked to interpret an ECG in the setting of cardiovascular evaluation of athletes. Stan- dard criteria for defining the limits of normal (or variation of normal) ECG in the athlete remain to be determined. The interpretation of the athlete’s ECG is often left to personal experi- ence and usually made according to traditional ECG criteria used in the general (non-athletic) population. Electrocardiogram changes in athletes are common and usually reflect structural and electrical remodelling of the heart as an adap- tation to regular physical training (athlete’s heart).3–10 However, abnormalities of athlete’s ECG may be an expression of an under- lying heart disease which carries a risk of SCD during sport.11 –13 It is important that ECG abnormalities resulting from intensive physical training and those potentially associated with an increased cardiovascular risk are correctly distinguished.14–17 Errors in differentiating between physiological and pathological ECG abnormalities may have serious consequences. Athletes may undergo expensive diagnostic work-up or may be unnecess- arily disqualified from competition for changes that fall within the normal range for athletes. This is of particular relevance for pro- fessional athletes in whom disqualification from competitive sports has significant financial and psychological consequences. Alternatively, signs of potentially lethal cardiovascular disorders may be misinterpreted as normal variants of an athlete’s ECG. A correct evaluation of 12-lead ECG patterns in the athlete and appropriate subsequent action has the potential to increase efficacy, accuracy, and cost-effectiveness of athlete’s cardiovascular evaluation.17–21 Some consider that physiological ECG changes overlap signifi- cantly with ECG abnormalities seen in the cardiovascular diseases which cause SCD in the young.14–16 The ECG has therefore been considered a non-specific and non-cost-effective tool for cardio- vascular evaluation of athletes because of a presumed high level of false-positive results. This concept was based on few studies of small and selected series of highly trained athletes from a limited number of sports disciplines. The 25-year Italian experience with universal pre-participation screening has offered the unique opportunity to investigate ECG changes in large cohorts of athletes, engaged in a broad variety of sports activities with different and well-characterized levels of training and fitness.22 –25 The currently available data allow an accurate redefinition of the spectrum of athlete’s ECG patterns and raise the need for a revision of accuracy, utility, and cost–benefit analysis of the use of ECG in the cardiovascular evaluation of the athlete. In addition, there is growing experience of early and incomplete disease expression of the inherited cardiomyopathies and arrhythmias which usually have ECG changes as their initial presentation.26,27 The present document is endorsed by the Sections of Sports Cardiology and Exercise Physiology of the European Association of Cardiovascular Prevention and Rehabilitation and by the Working Group on Myocardial and Pericardial diseases of the European Society of Cardiology and represents the position state- ment of an international panel of cardiologists and sports medical doctors with expertise in the field of cardiovascular evaluation of young competitive athletes. The article provides a modern approach to interpretation of 12-lead ECG in the athlete based on recently published new findings. The target audience are pri- marily sports medical doctors, sports cardiologists, and team phys- icians. The main objective is to differentiate between physiological adaptive ECG changes and pathological ECG abnormalities, with the aim to prevent adaptive changes in the athlete being erro- neously attributed to heart disease, or signs of life-threatening car- diovascular conditions being dismissed as normal variants of athlete’s heart. Because only pathological ECG abnormalities cause alarm and require action with additional testing to exclude (or confirm) the suspect of a lethal cardiovascular disorder, appropriate interpretation of an athlete’s ECG also results in a considerable cost savings in the context of a population-based pre- participation screening program.17 uploads/Voyage/ guide-ecg-sportivi.pdf

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