Athlete-Specific ECG Criteria Proposed for Sports Screening

May 08, 2014

SAN FRANCISCO, CA — Electrocardiogram interpretation using criteria designed specifically for athletes, may be superior to the history and physical recommended by the American Heart Association (AHA) for sports-participation screening, addressing a major weakness of the standard method, a high false-positive rate, according to a prospective study of >4800 high-school–aged athletes[1].

On their own, the history and physical showed a 50% false-positive rate for flagging persons at elevated risk, compared with only 4% for ECG, the latter interpreted using specific criteria developed largely at the University of Washington, Seattle, or those recommended by the European Society of Cardiology (ESC).

"A lot of the focus of the AHA has been using the history and physical to make decisions. But I don't think we have good data to necessarily support even that recommendation," Dr Jordan M Prutkin (University of Washington, Seattle), codeveloper of the Seattle criteria, told heartwire . The current study, which he presented here in poster form at the Heart Rhythm Society 2014 Scientific Sessions , "suggests that the history and physical may not be that good for picking up abnormalities that could put these athletes at risk of sudden death. We need to be looking at further screening methods such as an ECG to determine what best way to prevent sudden death in these young people."

Prutkin described the Seattle criteria as a refinement of the European Society of Cardiology (ESC) criteria. Both sets of criteria specifically don't flag certain training-associated ECG changes that would be noteworthy in the average middle-aged man or woman but are considered normal in athletes, including atrial ectopic beats; isolated QRS voltage criteria for LV hypertrophy; and J waves, ST-segment elevation, and some other signs of early repolarization.

Instead, Prutkin said, both sets of criteria focus on about a dozen ECG features suggesting possible high-risk cardiac pathology, each with athlete-specific definitions, that include inverted T waves, ST-segment depression, right ventricular hypertrophy patterns, ventricular preexcitation, and short and long QT intervals.

In the current study, 4812 teenaged athletes were screened at US high schools from October 2010 through June 2013. All completed a questionnaire with personal and family history screening questions like those recommended by the AHA and underwent 12-lead electrocardiography, with additional echocardiography for anyone with an abnormality on the other tests. The ESC criteria for interpreting ECGs of athletes were used for the first two-thirds of the cohort and the Seattle criteria for the latter one-third, Prutkin said. Women made up 46% of the group; 65% were white, 10% Asian, and 6% were African American.

The screening process identified "significant abnormalities requiring further evaluation" in 23 of the subjects, or about 0.5% of the cohort; they included nine cases of Wolff-Parkinson-White preexcitation, four anomalous coronary arteries, three dilated aortic roots or aneurysms, three cases of long-QT syndrome, two of hypertrophic cardiomyopathy, one of ventricular arrhythmia, and one of short-QT syndrome.

An abnormal history or physical pointed to the diagnoses in 61% of cases and an abnormal ECG in 70%. The rate of false-positive diagnoses was 50% for the initial history and physical (which improved to 32% after physician review), 4% for the ECG, and 35% for the postreview history and physical considered with the ECG.

"One of our planned studies will compare the Seattle criteria with the ESC criteria and even try to figure out, going forward, whether there are further refinements to the Seattle criteria that we can make," Prutkin said. Another issue is finding able interpreters of ECGs using the athlete-specific criteria. "You'd need to find people who could be trained to read these ECGs appropriately. That's going to be one of the difficulties in doing this."

Abnormalities pointing to possibly increased sudden-death risk in the Seattle criteria include:

  • T-wave inversion (defined as >1 mm in depth in two or more of leads V2-V6, II and aVF, or I and aVL).

  • Long QT interval (corrected QT [QTc] >470 ms in men, >480 ms in women ).

  • Short QT interval (QTc <320 ms).

  • ST-segment depression (>0.5 mm in two or more leads).

  • Pathologic Q waves (>3 mm in depth or >40 ms in duration in two or more leads, excluding III and aVR).

  • Left atrial enlargement (P-wave duration >120 ms in leads I or II with negative portion of the P wave >1 mm in depth and >40 ms in duration in lead V1).

  • Right ventricular hypertrophy (R-V1 + S-V5 >10.5 mm plus right axis deviation >120°).

  • Compete left bundle branch block (LBBB) or any QRS >140ms.

  • Mobitz type II 2° AV block or complete heart block.

  • Ventricular preexcitation (PR interval <120 ms with a delta wave and QRS >120 ms).

  • Profound sinus bradycardia defined as <30 beats per minute or sinus pauses >3 s.

  • Atrial tachyarrhythmias (supraventricular tachycardia or atrial fibrillation or flutter).

  • Premature ventricular contractions (>2 per 10 second tracing), ventricular arrhythmias (couplets, nonsustained VT).

  • Type 1 Brugada pattern.

Prutkin discloses receiving consulting fees or honoraria and research grants from Boston Scientific.

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