HKΓραφικές μεταβολές που υπονοούν μυοκαρδιοπάθεια στους αθλητές

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Θυώνη Καλαμογδάρτης
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1 HKΓραφικές μεταβολές που υπονοούν μυοκαρδιοπάθεια στους αθλητές Dr. Hλίας Θ. Ζάρβαλης Διευθυντής ΕΣΥ Καρδιολογική Κλινική ΓΝ Παπαγεωργίου Θεσσαλονίκη

2 Το παράδοξο της άθλησης Regular physical exercise is associated with a decrease in all cause-mortality, particularly from cardiovascular causes vigorous exertion may acutely and transiently increase the risk of acute coronary events and sudden cardiac arrest in susceptible Individuals

3 Causes of sudden cardiac death in young athletes the most common mechanism of SCD during sports activity is an abrupt ventricular tachyarrhythmia as a consequence of a wide spectrum of cardiovascular diseases Papadakis M et al. BMJ 2008;337:bmj.a1596

4 . pre-participation cardiovascular screening recommended by the European Society of Cardiology section of Sports Cardiology Corrado D et al. Eur Heart J 2011;32:

Annual incidence of sudden cardiovascular death in screened competitive athletes compared with non-athletes in Veneto region, Italy, 1979-2004.

5 Annual incidence of sudden cardiovascular death in screened competitive athletes compared with non-athletes in Veneto region, Italy, adding ECG to history and physical examination in the screening protocol of athletes aged years saves 2.06 life-years per 1000 athletes, at a cost of $42,000 per life-year saved

6 Athletes heart up to 60% of athletes demonstrate ECG changes Regular and long-term participation in intensive exercise (minimum of 4 h/week) is associated with unique electrical manifestations that reflect increased vagal tone and enlarged cardiac chamber size. The extent of these changes is also dependent on the athlete s ethnicity, age, gender, sporting discipline and level of training and competition These ECG findings in athletes are considered normal, physiological adaptations to regular exercise and do not require further evaluation

7 Concerns for the physician when interpreting an athlete s ECG missing a dangerous cardiac condition and generating false-positive interpretations that cause needless further investigations, increased economic cost and potentially unnecessary activity restriction for the athlete.

8 Drezner JA, et al. Br J Sports Med 2013;47:

9 The Seattle Criteria The effect of the use of the proposed modern criteria is to substantially increase the ECG specificity (by 70%), primarily in the important group of athletes who exhibit pure voltage criteria for left ventricular hypertrophy and early repolarization abnormalities, but with the important requisite of maintaining sensitivity for detection of cardiovascular diseases predisposing to SCD during sports. The criteria were developed with consideration of ECG interpretation in the context of an asymptomatic athlete age 14 35

10 Drezner JA, et al. Br J Sports Med 2013;47:

11 Drezner JA, et al. Br J Sports Med 2013;47:122

12 Corrado et al. European Heart Journal (2010) 31,

13 common and training-related ECG changes

14 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:

15 Isolated increase of QRS voltages Physiological LV hypertrophy in trained athletes usually manifests as an isolated increase of QRS amplitude, with normal QRS axis, normal atrial and ventricular activation patterns, and normal ST-segment T-wave repolarization LV hypertrophy differed with respect to the type of sports discipline and was more frequent in athletes engaged in endurance disciplines, such as cycling, cross-country skiing, and rowing/canoeing. male gender and increased cardiac dimensions and wall thickness. very uncommon finding in HCM patients do not require systematic echocardiographic evaluation, unless they have relevant symptoms, a family history of cardiovascular diseases, and/or SCD or non-voltage ECG criteria suggesting pathological LV hypertrophy.

16 Isolated increase of QRS voltages ECG of a 29-year-old asymptomatic soccer player Drezner J A et al. Br J Sports Med 2013;47:

17 Increased QRS Voltage The largest proportion of athletes with ECGs classified as abnormal using previous criteria exhibited isolated increases in QRS voltage (prevalence of up to 80% in some series).

18 uncommon and training-unrelated ECG changes

19 T wave inversion T-wave inversion >2 mm in two or more adjacent leads in an athlete is a non-specific warning sign of a potential cardiovascular disease at risk of SCD during sports T-wave inversion in inferior (II, III, avf) and/or lateral (I, avl, V5 V6) leads must raise the suspicion of ischaemic heart disease, cardiomyopathy, aortic valve disease, systemic hypertension, and LV non-compaction The post-pubertal persistence of T-wave inversion beyond V1 may reflect an underlying congenital heart disease leading to a RV volume or pressure overload state, ARVC, and uncommonly, an inherited ion-channel disease. Recent studies showed that T-wave inversion beyond V1 is seen in post-pubertal athletes less commonly than previously thought (,1.5%), but deserves special consideration because it may reflect underlying ARVC

20 Abnormal ECG in a patient with hypertrophic cardiomyopathy. Drezner J A et al. Br J Sports Med 2013;47:

21 ECG from a patient with arrhythmogenic right ventricular cardiomyopathy. Drezner J A et al. Br J Sports Med 2013;47:

22 ECG from a patient with arrhythmogenic right ventricular cardiomyopathy showing delayed S wave upstroke in V1 (arrow), low voltages in limb leads <5 mm (circles), and inverted T waves in anterior precordial leads (V1 V4) and inferior leads (III and avf). Drezner J A et al. Br J Sports Med 2013;47:

23 athletes of African/Caribbean origin inverted T-waves, usually preceded by ST-segment elevation, commonly observed in leads V2 V4 (up to 25% of cases) and represent adaptive early repolarization changes which normalize during exercise or adrenergic stimulation. On the contrary, T-wave inversion in inferior (L2, L3, avf) and/or lateral leads (L1, avl, V5, and V6) are uncommon even in black athletes and warrant further investigation for excluding an underlying heart disease.

24 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:

25 Normal variant repolarisation changes in a black/african athlete characterised by domed ST segment elevation and T wave inversion in V1 V4. Drezner J A et al. Br J Sports Med 2013;47:

26 ST segment depression extremely rare in otherwise healthy athletes Any degree of ST depression beyond 0.5 mm in two or more leads is significant and requires further investigation for cardiomyopathy

27 Pathological Q waves define Q waves for HCM as >3mm in depth or >40 ms in duration in at least two leads (excluding leads III and avr) This detects HCM with a sensitivity of 35% and a specificity of 95% in patients with preclinical HCM based on molecular genetic diagnosis

28 Abnormal ECG in a patient with hypertrophic cardiomyopathy. Drezner J A et al. Br J Sports Med 2013;47:

Left atrial enlargement ECG in a patient with hypertrophic cardiomyopathy showing left atrial enlargement LAE is defined as a prolonged P wave duration of >120 ms in leads I or

29 Left atrial enlargement ECG in a patient with hypertrophic cardiomyopathy showing left atrial enlargement LAE is defined as a prolonged P wave duration of >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. LAE on ECG is an uncommon finding in athletes and should prompt additional investigation.

30 Intraventricular conduction delay Demonstration of complete bundle branch block and/or hemiblock in an athlete should lead to a cardiological work-up (RBBB) is found more commonly in HCM than in athletes but the frequency of incomplete and complete RBBB in athletes is felt to limit its differentiating value. marked non-specific IVCD >140 ms is considered abnormal and should prompt further evaluation The significance of a non-specific intraventricular conduction delay (IVCD) with normal QRS morphology is uncertain.

31 Abnormal ECG in a patient with hypertrophic cardiomyopathy showing complete left bundle branch block (QRS 120 ms with predominantly negative QRS complex in lead V1). Drezner J A et al. Br J Sports Med 2013;47:

32 Isolated premature ventricular contractions multiple PVCs (2 or more) during a single ECG tracing (10 s), multifocal PVCs or PVCs found in tandem with other abnormal ECG findings likelihood is very high that the athlete has >2000 PVCs per 24 h. In athletes with >2000 PVCs per 24 h, underlying structural heart disease which may predispose to more lifethreatening ventricular arrhythmias was found in 30% of cases, compared to only 3% of athletes with PVCs, and 0% of athletes with <100 PVCs on a 24 h Holter. Over half of the athletes with >2000 PVCs also had bursts of nonsustained ventricular tachycardia. Therefore, a structural cardiac abnormality should be ruled out in athletes with >2000 PVCs per 24 h.

33 ECG from a patient with arrhythmogenic right ventricular cardiomyopathy. Drezner J A et al. Br J Sports Med 2013;47:

34 Right atrial enlargement and right ventricular hypertrophy uncommon findings in athletes Sokolow Lyon voltage criteria for RV hypertrophy (R- VI+S-V5>10.5 mm) were seen in 0.6% professional soccer players should not be interpreted as a manifestation of exercise-induced cardiac remodelling

35 ECG from a patient with pulmonary hypertension

36 Accuracy of ECG interpretation by specialty before and after criteria tool. Drezner J A et al. Br J Sports Med 2012;46:

37 Accuracy of ECG interpretation by diagnosis. Drezner J A et al. Br J Sports Med 2012;46:

38 Συμπεράσματα Ι Τα σύγχρονα κριτήρια ερμηνείας του ΗΚΓ των αθλητών έχουν αυξήσει την ειδικότητα διατηρώντας την ευαισθησία ανίχνευσης υποκείμενων μυοκαρδιοπαθειών που μπορούν να οδηγήσουν σε αιφνίδιο καρδιακό θάνατο. Τα μεμονωμένα υψηλά δυναμικά QRS που δεν συνοδεύονται από άλλες ΗΚΓφικές ενδείξεις υπερτροφίας, σε αθλητές χωρίς σχετικά συμπτώματα και με αρνητικό οικογενειακό ιστορικό μυοκαρδιοπάθειας ή αιφνίδιου καρδιακού θανάτου είναι ενδεικτικά καλοήθους υπερτροφίας και δεν χρήζουν περαιτέρω διερεύνησης

39 Συμπεράσματα ΙΙ Η παρουσία: αρνητικών Τ, κατασπάσεων του ST διαστήματος, παθολογικών Q, η διάταση του αριστερού κόλπου, σκελικών αποκλεισμών ή ημιαποκλεισμών, συχνών έκτακτων κοιλιακών συστολών και ενδείξεων υπερτροφίας δεξιάς κοιλίας πρέπει να διερευνούνται περαιτέρω.

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