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The Athlete's ECG: ESC and Seattle Criteria

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Jacob Kelly, MD
Duke University Medical Center

Published in: Health & Medicine
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The Athlete's ECG: ESC and Seattle Criteria

  1. 1. The Athlete’s ECG – ESC and Seattle Criteria Jacob Kelly, MD 2nd Annual Duke Sports Cardiology & Sudden Death in Athletes Summit
  2. 2. ECG Screening for Athletes •  What is a “normal” ECG for an athlete? –  Seattle criteria –  ESC Criteria •  ECG Cases/Examples –  Racial, ethnic, sports-specific & others •  Criteria Criteria – a comparison of the current ECG Screening criteria
  3. 3. Seattle criteria – Normal ECG findings Drezner JA, Fischbach P, Froelicher V, et al. Br J Sports Med 2013;47:125–136.
  4. 4. Seattle Criteria – Abnormal ECGs in athletes
  5. 5. ESC ECG Criteria for Athletes Corrado, EHJ 2010
  6. 6. Corrado et al. J Am Coll Cardiol 2008:52:1981-89.
  7. 7. Chandra N, JACC 2014
  8. 8. Chandra N, JACC 2014
  9. 9. Chandra N, JACC 2014
  10. 10. Chandra N, JACC 2014
  11. 11. Normal variant in black athlete V1-V4 (not V5-V6) and often preceded by convex ST-segment elevation Wilson B et al, Br J Sports Med 2012 46: i51-
  12. 12. ECG examples demonstrating common repolarization changes in black individuals Papadakis M et al. Eur Heart J 2011;32:2304-2313
  13. 13. Papadakis M et al. Eur Heart J 2011;32:2304-2313
  14. 14. (A) Histogram demonstrating the prevalence of repolarization changes as percentage (%) of the total cohort in black athletes, black controls, and black hypertrophic cardiomyopathy patients groups.
  15. 15. Abnormal ECG in Both Kinds of Football Players •  Schmied: 25.8% of U-17 African elite football players by 2005 ESC, 19.5% distinctly abnormal by Pelliccia criteria (36.4% mildly abnormal). •  (20%) had significant T wave inversions in the anterior and/or lateral leads…none of the abnormal ECG findings we observed was related to an unequivocal structural abnormality on echocardiography. Schmied, Br J Sports Med 2009;43:716 Magalski : 25% of elite American football (NFL) players and twice as many black players (30%) vs white (13%) had an abnormal ecg; wide receivers >quarterbacks, kickers. Magalski, J Am Coll Cardiol, 2008; 51:2250
  16. 16. Evaluation of ECG Abnormalities in Italian Olympic Athletes Pelliccia A et al, Circulation 2000; 102: 278
  17. 17. Pelliccia A et al, Circulation 2000; 102: 278 Evaluation of ECG Abnormalities in Italian Olympic Athletes
  18. 18. Pellicia A et al, N Engl J Med 2008; 358:152 Repolarization changes •  81 of 12,550 trained athletes had deeply inverted T- waves ≥ 2 mm in at least 3 leads without other apparent cardiac dz •  5/81 (6%) eventually manifested cardiomyopathy (3 HCM, 1 DCM, 1 ARVC)
  19. 19. ECG of a 28-year-old asymptomatic Caucasian handball player demonstrating a junctional escape rhythm Drezner J A et al. Br J Sports Med 2013;47:125-136 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  20. 20. ECG shows Mobitz type I (Wenckebach) second-degree AV block demonstrated by progressively longer PR intervals until there is a non- conducted P wave (arrows) and no QRS complex. Drezner J A et al. Br J Sports Med 2013;47:125-136 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  21. 21. ECG of a 29-year-old asymptomatic soccer player demonstrating sinus bradycardia, early repolarisation with ST elevation (arrows) and peaked T waves, and voltage criteria for left ventricular hypertrophy. Drezner J A et al. Br J Sports Med 2013;47:125-136 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  22. 22. ECG shows first-degree AV block (PR interval >200 ms). Drezner J A et al. Br J Sports Med 2013;47:125-136 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  23. 23. ECG shows Mobitz type I (Wenckebach) second-degree AV block demonstrated by progressively longer PR intervals until there is a non-conducted P wave (arrows) and no QRS complex. Drezner J A et al. Br J Sports Med 2013;47:125-136 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  24. 24. (A and B) Classic definition of early repolarisation based on ST elevation at QRS end (J- point). Drezner J A et al. Br J Sports Med 2013;47:125-136 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  25. 25. (A) Borderline Brugada-ECG pattern mimicking incomplete RBBB. Unlike the ‘R-wave’ of RBBB, the ‘J-wave’ (arrows) of Brugada-ECG is confined to right precordial leads (V1 and V2) without reciprocal ‘S-wave’ (of comparable voltage and duration) in the leads L1 and V6 (arrowhead). Corrado D et al. Eur Heart J 2010;31:243-259 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org
  26. 26. Different patterns of precordial early repolarization in two healthy athletes Corrado D et al. Eur Heart J 2010;31:243-259 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org
  27. 27. Differential diagnosis between representative right precordial ECG patterns from (A) a Brugada patient and (B) two trained athletes. Corrado D et al. Eur Heart J 2010;31:243-259 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org
  28. 28. ECG from a 19-year-old asymptomatic soccer player demonstrating voltage criteria for LVH (S-V1+R-V5>35 mm) Drezner J A et al. Br J Sports Med 2013;47:125-136 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  29. 29. Abnormal ECG from a patient with hypertrophic cardiomyopathy Drezner J A et al. Br J Sports Med 2013;47:125-136 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  30. 30. ECG (left panel) and cardiac MRI (right panel) of apical hypertrophic cardiomyopathy Drezner J A et al. Br J Sports Med 2013;47:137-152 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  31. 31. ECG from a 17-year-old black/African soccer player demonstrating ‘domed’ ST elevation followed by T wave inversion in leads V1–V4 (circles) Drezner J A et al. Br J Sports Med 2013;47:137-152 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  32. 32. ECG demonstrates abnormal left-axis deviation defined as frontal plane QRS axis of less than −30° Drezner J A et al. Br J Sports Med 2013;47:137-152 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
  33. 33. Criteria Comparison
  34. 34. Criteria Comparison
  35. 35. Criteria Comparison
  36. 36. Bethesda vs ESC Sports Exclusion Pelliccia et al, J Am Coll Cardiol, 2008; 52:1990
  37. 37. Resources regarding ECG’s in athletes

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