ΠΕΡΙΠΤΩΣΗ ΕΝΔΙΑΦΕΡΟΝ ΠΡΟΑΘΛΗΤΙΚΟ ΗΚΓ ΝΕΑΡΟΥ ΠΟΔΟΣΦΑΙΡΙΣΤΗ 16 ΕΤΩΝ

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1 ΠΕΡΙΠΤΩΣΗ ΕΝΔΙΑΦΕΡΟΝ ΠΡΟΑΘΛΗΤΙΚΟ ΗΚΓ ΝΕΑΡΟΥ ΠΟΔΟΣΦΑΙΡΙΣΤΗ 16 ΕΤΩΝ

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4 1 η ΕΡΩΤΗΣΗ ΕΙΝΑΙ ΤΟ ΠΑΡΑΠΑΝΩ ΗΚΓ: 1. οριακό-borderline 2. φυσιολογικό για την ηλικία του νεαρού 3. παθολογικό για την ηλικία του νεαρού

5 An athlete is defined as an individual who engages in regular exercise or training for sport or general fitness, typically with a premium on performance, and often engaged in individual or team competition at least 4 8 hours per week

6 the Seattle Criteria I Electrocardiographic interpretation in athletes: The Seattle Criteria. Drezner JA,et albr J Sports Med2013

7 the Seattle Criteria II Electrocardiographic interpretation in athletes: The Seattle Criteria. Drezner JA,et albr J Sports Med2013

8 ΑΠΑΝΤΗΣΗ

9 1 η ΑΠΑΝΤΗΣΗ ΣΥΜΦΩΝΑ ΜΕ ΤΑ ΚΡΙΤΗΡΙΑ SEATL 2013 KAI ΕΦΟΣΟΝ ΤΟ ΕΥΡΗΜΑ ΑΦΟΡΑ NON BLACK ATHLETE TO HKG ΕΥΡΗΜΑ ΘΑ ΜΠΟΡΟΥΣΕ ΝΑ ΘΕΩΡΗΘΕΙ ΜΗ ΦΥΣΙΟΛΟΓΙΚΟ Σωστή απάντηση η 3

10 2 η ΕΡΩΤΗΣΗ Εφόσον το ΗΚΓ θεωρηθεί ως μη φυσιολογικό, τι συστάσεις θα δίνατε κατ αρχάς στον νεαρό αθλητή σε σχέση με την άθληση? 1.ΝΑ ΣΤΑΜΑΤΗΣΕΙ ΤΗΝ ΑΘΛΗΣΗ 2.ΝΑ ΣΥΝΕΧΙΣΕΙ ΝΑ ΑΘΛΗΤΑΙ 3.ΝΑ ΣΥΝΕΧΙΣΕΙ ΝΑ ΑΘΛΗΤΑΙ,ΟΧΙ ΟΜΩΣ ΑΝΤΑΓΩΝΙΣΤΙΚΑ 4.ΝΑ ΣΤΑΜΑΤΗΣΕΙ ΝΑ ΑΘΛΗΤΑΙ ΜΕΧΡΙ ΤΗΝ ΟΛΟΚΛΗΡΩΣΗ ΤΩΝ ΠΕΡΑΙΤΕΡΩ ΕΞΕΤΑΣΕΩΝ

11 From: Recommendations for interpretation of 12-lead electrocardiogram in the athlete Eur Heart J. 2009;31(2): doi: /eurheartj/ehp473 Eur Heart J Published on behalf of the European Society of Cardiology. All rights reserved. The Author For permissions please journals.permissions@oxfordjournals.org

12 athletes with abnormal ECG findings of uncertain clinical significance should be recommended temporary absence from athletic activity until the completion of further examinations are required for the investigation. Electrocardiographic interpretation in athletes: The Seattle Criteria. Drezner JA,et albr J Sports Med2013

13 ΑΠΑΝΤΗΣΗ

14 2 η ΑΠΑΝΤΗΣΗ Εφόσον θεωρηθεί ως μη φυσιολογικό το ΗΚΓ συστήνεται η διακοπή της άθλησης μέχρι την ολοκλήρωση των εξετάσεων. Σωστή απάντηση η 4

15 3 η ΕΡΩΤΗΣΗ Ποια η πιθανή νόσος που υποπτεύεσθε από το παραπάνω ΗΚΓ? 1.HCM 2.ARVC 3. Brugada pattern 4. abnormalities of the coronary arteries 5. τίποτε από τα παραπάνω

16 ECG from a 30-year-old patient with ARVC showing anterior TWI in V1-V3 preceded by a flat or downsloping ST segment without J-point elevation. Jonathan A Drezner et al. Br J Sports Med 2017;51:

17 ECG in a young athlete with arrhythmogenic right ventricular cardiomyopathy showing several abnormal features including anterior T wave inversion (V1 V4) preceded by a nonelevated J-point and ST segment, an epsilon wave in V1 (magnified and marked with arrow), delayed S wave upstroke in V2, and low voltage (<5 mm) QRS complexes in limb leads I and avl. Jonathan A Drezner et al. Br J Sports Med 2017;51:

18 ECG from a patient with arrhythmogenic right ventricular cardiomyopathy. Jonathan A Drezner et al. Br J Sports Med 2017;51:

19 coronary artery disease is rare in individuals <40 years of age, whereas coronary anomalies tend not to be associated with myocardial infarction. Recommended that HCM criteria for Q waves be used in young athletes (>3 mm in depth and/or >40 ms duration in any lead except AVR, III, and V1). We do not endorse the use of standard coronary disease criteria for Q waves in young athletes, but they should apply in athletes >40 years of age

20 A 5-mm Q wave in lead V5 in a patient with hypertrophic cardiomyopathy. Abhimanyu Uberoi et al. Circulation. 2011;124: Copyright American Heart Association, Inc. All rights reserved.

21 ECG from an 18-year-old female swimmer demonstrating deep and wide pathological Q waves in V4-V6, I and avl. Jonathan A Drezner et al. Br J Sports Med 2017;51: hypertrophic cardiomyopathy 32% 42% of patients.

22 (A) ECG from an 18-year-old black basketball player demonstrating abnormal TWI extending into V5. Jonathan A Drezner et al. Br J Sports Med 2017;51:

23 Brugada type 1 ECG (left) should be distinguished from early repolarisation with convex ST segment elevation in a trained athlete (right). Jonathan A Drezner et al. Br J Sports Med 2017;51: Corrado index STJ/ST80 ratio >1 Brugada pattern STJ/ST80 ratio <1 early repolarisation

24 The ECG can not detect the presence of congenital abnormalities of the coronary arteries, early coronary artery disease and aortic disorders

25 ΑΠΑΝΤΗΣΗ

26 ΑΠΑΝΤΗΣΗ 3 η Με βάση τα προηγούμενα σωστή απάντηση είναι η 5

27 International recommendations for electrocardiographic interpretation in athletes

28 International consensus standards for ECG interpretation in athletes. AV, atrioventricular; LBBB, left bundle branch block; LVH, left ventricular hypertrophy; PVC, premature ventricular contraction; RBBB, right bundle branch block; RVH, right ventricular hypertrophy; SCD, sudden cardiac death. Jonathan A Drezner et al. Br J Sports Med 2017;51:

29 T-wave inversion From: International recommendations for electrocardiographic interpretation in athletes Eur Heart J. Published online February 20, doi: /eurheartj/ehw631 Eur Heart J The Author This article has been co-published in the European Heart Journal and the Journal of the American College of Cardiology. An extended version of this article has also been jointly published in the British Journal of Sports Medicine.

30 NORMAL ECG FINDINGS IN ATHLETES Left and right ventricular hypertrophy Early repolarization juvenile electrocardiographic pattern Physiological arrhythmias of athletes

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32 ΕΡΩΤΗΣΗ 4 η Με βάση τα τροποποιημένα κριτήρια SEATL το παραπάνω ΗΚΓ είναι: 1.παθολογικό 2.φυσιολογικο-Juvenille 3.οριακο-borderline

33 hypertrophy, J point elevation and convex ( domed ) ST segment elevation followed by T-wave inversion in V1 V4 From: International recommendations for electrocardiographic interpretation in athletes Eur Heart J. Published online February 20, doi: /eurheartj/ehw631 Eur Heart J The Author This article has been co-published in the European Heart Journal and the Journal of the American College of Cardiology. An extended version of this article has also been jointly published in the British Journal of Sports Medicine.

34 juvenile electrocardiographic pattern negative or biphasic T in leads beyond V2 on teen ECG Occurs in 10-15% of adolescent white athletes aged 12 years and in 2.5% of adolescent white athletes aged negative T in leads beyond V2 in white athletes> 16 years is rare (0.1%) International consensus standards for ECG interpretation in athletes-seattle 2017

35 combination of J-point elevation 1mm and TWI A recent study comparing anterior TWI in a series of black and white healthy athletes, patients with HCM and patients with ARVC showed that in athletes with anterior TWI, the combination of J- point elevation 1mm and TWI confined to leads V1-V4 excluded either cardiomyopathy with 100% negative predictive value, regardless of ethnicity Conversely, anterior TWI associated with minimal or absent J-point elevation (<1mm) could reflect a cardiomyopathy.

36 Calore C, Zorzi A, Sheikh N, et al Electrocardiographic anterior T-wave inversion in Athletes of different ethnicities: differential diagnosis between athlete's heart and cardiomyopathy. Eur Heart J 2016;37:

37 electrocardiographic anterior T-wave inversion in Athletes of different ethnicities: differential diagnosis between athlete's heart and cardiomyopathy From: Electrocardiographic anterior T-wave inversion in athletes of different ethnicities: differential diagnosis between athlete's heart and cardiomyopathy Eur Heart J. 2015;37(32): doi: /eurheartj/ehv591 Eur Heart J Published on behalf of the European Society of Cardiology. All rights reserved. The Author For permissions please journals.permissions@oup.com.

38 electrocardiographic anterior T-wave inversion in Athletes of different ethnicities: differential diagnosis between athlete's heart and cardiomyopathy From: Electrocardiographic anterior T-wave inversion in athletes of different ethnicities: differential diagnosis between athlete's heart and cardiomyopathy Eur Heart J. 2015;37(32): doi: /eurheartj/ehv591 Eur Heart J Published on behalf of the European Society of Cardiology. All rights reserved. The Author For permissions please journals.permissions@oup.com.

39 ΑΠΑΝΤΗΣΗ

40 ΑΠΑΝΤΗΣΗ 4η Με βάση τα παραπάνω η σωστή απάντηση είναι η 2.

41 ΕΥΧΑΡΙΣΤΩ

42 PATHOLOGICAL EKG FINDINGS Pathological negative T (negative T with depth 1 mm in at least 2 adjacent leads) Biphasic T when their negative part has a depth 1 mm in at least two adjacent leads. Negative T in lateral and lower lateral leads Exceptions: black athletes with elevation, white athletes <16 years, biphasic T only V3 International consensus standards for ECG interpretation in athletes-seattle 2017

43 Specific information about the J-point and preceding ST segment may help differentiate between physiological adaptation and cardiomyopathy in athletes with anterior TWI affecting leads V3 and/or V4. A recent study comparing anterior TWI in a series of black and white healthy athletes, patients with HCM and patients with ARVC showed that in athletes with anterior TWI, the combination of J-point elevation 1mm and TWI confined to leads V1-V4 excluded either cardiomyopathy with 100% negative predictive value, regardless of ethnicity. Conversely, anterior TWI associated with minimal or absent J-point elevation (<1mm) could reflect a cardiomyopathy. These data require duplication in larger studies but may prove useful in the assessment of a small proportion of white endurance athletes who exhibit anterior TWI and in athletes of black/mixed ethnicity excludes: black athletes with J-point elevation and convex ST segment elevation followed by TWI in V2-V4; athletes < age 16 with TWI in V1-V3; and biphasic T waves in only V3

44 PATHOLOGICAL EKG FINDINGS ΙΙ ST depression Pathological Waves Q LBBB Nonspecific intraventricular delay (QRS range 140 ms) ventricular prexcitation QT prolongation Type I Bruganda Mobitz II, complete atrioventricular block Atrial flutter and atrial fibrillation ventricular arrhythmias

45 In athletes age 16 years with TWI beyond V2, concurrent findings of J-point elevation, ST segment elevation or biphasic T waves more likely represent athlete s heart, while the absence of J-point elevation or a coexistent depressed ST segment is more concerning for ARVC. Other ECG findings suggestive of ARVC in the presence of anterior TWI include low limb lead voltages, prolonged S wave upstroke, ventricular ectopy with LBBB morphology and epsilon waves