ECG changes in athletes

Last reviewed 03/2022

• there is a wider range of normality in ECGs of athletes than the 'normal population'
• some possible ECG features seen in an athlete have been described by Hampton and include (1)
  • there is often a sinus bradycardia due to increased levels of physical fitness
  • there may be first degree heart block or second degree heart block of the Wenkebach type
  • width of QRS is normal
  • it is relatively common to find tall complexes in V5 and deep S waves in V1 and V2 - this may show the so-called 'voltage criteria' for left ventricular hypertrophy (R plus S greater than 35 mm)
    
    
• a more detailed review of ECG abnormalities in the athlete population has been undertaken (2,3)
  • 7% of young athletes have an abnormal ECG compared with 40% of adult elite athletes
    • the difficulty lies in differentiating between what is normal for an athlete and what requires further investigation
      • A table looking to differentiate between Athlete's Heart, and ECGs requiring further investigation has been produced by Corrado et al (2)
        
        

• Group 1: common and training-related ECG changes	Group 2: uncommon and training-unrelated ECG changes
  Sinus bradycardia First-degree AV block Incomplete RBBB Early repolarization Isolated QRS voltage criteria for left ventricular hypertrophy	T-wave inversion ST-segment depression Pathological Q-waves Left atrial enlargement Left-axis deviation/left anterior hemiblock Right-axis deviation/left posterior hemiblock Right ventricular hypertrophy Ventricular pre-excitation Complete LBBB or RBBB Long- or short-QT interval Brugada-like early repolarization

  • RBBB, right bundle branch block; LBBB, left bundle branch block.
• a patient with ECG abnormalities in group 2 requires further investigation
• a patient with no other worrying features on clinical evaluation with group 1 changes only will likely be fit to participate

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Contributors:

• Dr Andrew Murray, Dr Duncan Goodall
  • Marathon Medical Services
• Prof Hillis
  • Professor of Cardiology and Exercise Medicine, University of Glasgow

Reference:

• 1) Hampton J. Update (8/7/99);79-82
• 2) Corrado D, Pelliccia A, Heidbuchel H, Sharma S, Link M, Basso C, Biffi A, Buja G, Delise P, Gussac I, Anastasakis A, Borjesson M, Bjørnstad HH, Carrè F, Deligiannis A, Dugmore D, Fagard R, Hoogsteen J, Mellwig KP, Panhuyzen-Goedkoop N, Solberg E, Vanhees L, Drezner J, Estes NA 3rd, Iliceto S, Maron BJ, Peidro R, Schwartz PJ, Stein R, Thiene G, Zeppilli P, and McKenna WJ. Recommendations for interpretation of 12-lead electrocardiogram in the athlete. Eur Heart J 2010 Jan; 31(2) 243-59.
• 3) Pelliccia A, Culasso F, Di Paolo FM, Accettura D, Cantore R, Castagna W, Ciacciarelli A, Costini G, Cuffari B, Drago E, Federici V, Gribaudo CG, Iacovelli G, Landolfi L, Menichetti G, Atzeni UO, Parisi A, Pizzi AR, Rosa M, Santelli F, Santilio F, Vagnini A, Casasco M, and Di Luigi L. Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Heart J 2007 Aug; 28(16) 2006-10. doi:10.1093/eurheartj/ehm219 pmid:17623682