Last update: May 2020


Cardiovascular causes of sudden death in young competitive athletes in the United States

  Most common: Hypertrophic cardiomyopathy, Congenital coronary artery anomaly

  Less common: Myocarditis, Aortic rupture (Marfan syndrome), Mitral valve prolapse.

  Uncommon: Arrhythmogenic RV cardiomyopathy, Atherosclerotic coronary artery disease, Conduction system abnormalities, Aortic valve stenosis




The following ECG abnormalities may be observed in well-trained athletes and are not generally regarded as abnormal

  Sinus bradycardia.
- Normally heart rate should increase during exercise in athletes (as in normal healthy population).
- In athletes, sinus bradycardia generally does not result in syncope or dizziness.
- In athletes, no further investigation is needed unless heart rate decreases below 30/minute at rest.
- The sinus bradycardia at rest
may diasappear after cessation of professional athletic training .

  Sinus arrhythmia. No need for further investigation unless there is a pause > 3 seconds while the patient is awake (during daytime).

  Early repolarization (in 50% of the athletes)

  Black athlete early repolarization variant: J-point elevation and convex (‘domed’) ST-segment elevation followed by T-wave inversion in leads V1-V4 in black athletes.

  Ectopic atrial rhythm

  Junctional rhythm

  Increased QRS voltage for left ventricular hypertrophy or right ventricular hypertrophy

  First-degree atrioventricular (AV) block (35%).
Generally disappears during exercise (If PR interval ≥ 400 ms, this is abnormal and needs further investigation).

  2nd degree, type 1 (Wenkebach) atrioventricular (AV) block (10%).
Generally disappears during exercise .

  Incomplete right bundle branch block (35%) (
may disappear after the cessation of professional athletic training ).

  Persistent juvenile T pattern (negative T waves in leads V1 to V3)




The following ECG abnormalities are borderline. Further investigation is needed if ≥ 2 of them are observed in an athlete:

  Left atrial abnormality

  Right atrial abnormality

  Left axis deviation (-30° to -90°)

  Right axis deviation (>120°)

  Complete right bundle branch block: rSR' pattern in lead V1 and a S wave wider than R wave in lead V6 with QRS duration ≥ 120 ms




The following ECG abnormalities are not related to sports. When observed in an athlete's ECG, they call for further investigation:

  T wave negativity other than juvenile T wave pattern (≥ 1 mm in depth in two or more contiguous leads; excludes leads aVR, III, and V1):
- Negative T waves in lateral or inferior leads is usually abnormal.
- Deep T wave negativity in any lead.

  ST segment depression ≥ 0.5 mm in depth in two or more contiguous leads.

  Left atrial abnormality

  Pathologic Q waves: Q/R ratio ≥ 0.25 or ≥ 40 ms in duration in two or more leads (excluding III and aVR).

  QRS ≥ 140 ms duration

  Epsilon wave

  Profound sinus bradycardia ( < 30 beat/minute)

  PR interval ≥ 400 ms

  Atrial tachyarrhythmias (supraventricular tachycardia, atrial fibrillation, atrial flutter)

  Ventricular arrhythmias (including 2 or more VPCs per 10 s tracing)

  Complete AV block

  Mobitz type II, 2nd degree AV block: Intermittently non-conducted P waves with a fixed PR interval.

  Complete left bundle branch block: QRS ≥ 120 ms, predominantly negative QRS complex in lead V1 (QS or rS), and upright notched or slurred R wave in leads I and V6

  Preexcitation pattern

  Prolonged QT interval: QTc ≥ 470 ms (male), QTc ≥ 480 ms (female), QTc ≥ 500 ms (marked QT prolongation)

  Short QT interval

  Brugada Type 1 pattern




References

  J Am Coll Cardiol 2017;69:1057-1075. (International Recommendations for Electrocardiographic Interpretation in Athletes.) (free full-text)

  Eur Heart J 2009;30:1728-1735.

  Eur Heart J 2010;31,243-259.

  European Heart Journal 2005;26:516-524
. (ESC Report Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol) (free full-text)





ECG 1. The ECG above belongs to a 38 years-old professional football player.
His ECHOcardiography and treadmill exercise tests were normal.
Sinus bradycardia is seen. He does not take any heart rate slowing medication.

Click here for a more detailed ECG