Chad A. Asplund

Electrocardiographic interpretation in athletes: the ‘Seattle Criteria’

Sudden cardiac death (SCD) is the leading cause of death in athletes during sport. Whether obtained for screening or diagnostic purposes, an ECG increases the ability to detect underlying cardiovascular conditions that may increase the risk for SCD. In most countries, there is a shortage of physician expertise in the interpretation of an athletes ECG. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from abnormal findings suggestive of pathology. On 13–14 February 2012, an international group of experts in sports cardiology and sports medicine convened in Seattle, Washington, to define contemporary standards for ECG interpretation in athletes. The objective of the meeting was to develop a comprehensive training resource to help physicians distinguish normal ECG alterations in athletes from abnormal ECG findings that require additional evaluation for conditions associated with SCD.

Normal electrocardiographic findings: recognising physiological adaptations in athletes

Electrocardiographic changes in athletes are common and usually reflect benign structural and electrical remodelling of the heart as a physiological adaptation to regular and sustained physical training (athletes heart). The ability to identify an abnormality on the 12-lead ECG, suggestive of underlying cardiac disease associated with sudden cardiac death (SCD), is based on a sound working knowledge of the normal ECG characteristics within the athletic population. This document will assist physicians in identifying normal ECG patterns commonly found in athletes. The ECG findings presented as normal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

Abnormal electrocardiographic findings in athletes: recognising changes suggestive of cardiomyopathy

Cardiomyopathies are a heterogeneous group of heart muscle diseases and collectively are the leading cause of sudden cardiac death (SCD) in young athletes. The 12-lead ECG is utilised as both a screening and diagnostic tool for detecting conditions associated with SCD. Fundamental to the appropriate evaluation of athletes undergoing ECG is an understanding of the ECG findings that may indicate the presence of an underlying pathological cardiac disorder. This article describes ECG findings present in cardiomyopathies afflicting young athletes and outlines appropriate steps for further evaluation of these ECG abnormalities. The ECG findings defined as abnormal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

Abnormal electrocardiographic findings in athletes: recognising changes suggestive of primary electrical disease

Cardiac channelopathies are potentially lethal inherited arrhythmia syndromes and an important cause of sudden cardiac death (SCD) in young athletes. Other cardiac rhythm and conduction disturbances also may indicate the presence of an underlying cardiac disorder. The 12-lead ECG is utilised as both a screening and a diagnostic tool for detecting conditions associated with SCD. Fundamental to the appropriate evaluation of athletes undergoing ECG is an understanding of the ECG findings that may indicate the presence of a pathological cardiac disease. This article describes ECG findings present in primary electrical diseases afflicting young athletes and outlines appropriate steps for further evaluation of these ECG abnormalities. The ECG findings defined as abnormal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

Abnormal electrocardiographic findings in athletes

Cardiomyopathies are a heterogeneous group of heart muscle diseases and collectively are the leading cause of sudden cardiac death (SCD) in young athletes. The 12-lead ECG is utilised as both a screening and diagnostic tool for detecting conditions associated with SCD. Fundamental to the appropriate evaluation of athletes undergoing ECG is an understanding of the ECG findings that may indicate the presence of an underlying pathological cardiac disorder. This article describes ECG findings present in cardiomyopathies afflicting young athletes and outlines appropriate steps for further evaluation of these ECG abnormalities. The ECG findings defined as abnormal in athletes were established by an international consensus panel of experts in sports cardiology and sports medicine.

International recommendations for electrocardiographic interpretation in athletes

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On February 26-27, 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

Exercise-associated collapse: an evidence-based review and primer for clinicians

Exercise-associated collapse (EAC) commonly occurs after the completion of endurance running events. EAC is a collapse in conscious athletes who are unable to stand or walk unaided as a result of light headedness, faintness and dizziness or syncope causing a collapse that occurs after completion of an exertional event. Although EAC is perhaps the most common aetiology confronted by the medical provider attending to collapsed athletes in a finish-line tent, providers must first maintain vigilance for other potential life-threatening aetiologies that cause collapse, such as cardiac arrest, exertional heat stroke or exercise-associated hyponatraemia. Previously, it has been believed that dehydration and hyperthermia were primary causes of EAC. On review of the evidence, EAC is now believed to be principally the result of transient postural hypotension caused by lower extremity pooling of blood once the athlete stops running and the resultant impairment of cardiac baroreflexes. Once life-threatening aetiologies are ruled out, treatment of EAC is symptomatic and involves oral hydration and a Trendelenburg position – total body cooling, intravenous hydration or advanced therapies is generally not needed.

International criteria for electrocardiographic interpretation in athletes: consensus statement

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26–27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

Facial protection and head injuries in ice hockey: a systematic review

Objective: To summarise the best available evidence to determine if facial protection reduces head injury in ice hockey. Data Sources: MEDLINE and Cochrane databases through January 2009. Review Methods: Utilising terms: “head injuries,” “craniocerebral trauma [MeSH]”, “head injuries, closed [MeSH]”, head injuries, penetrating [MeSH]”, “face mask”, “face shield”, “visor” and “hockey”, 24 articles were identified through our systematic literature search. Of these, six studies met the inclusion criteria. Three independent reviewers reviewed the articles. The study results and generated conclusions were extracted and agreed upon. Results: Studies reviewed suggest that facial protection reduces overall head injuries in ice hockey. Facial protection showed a statistically significant (p<0.05) reduction in the number and type of facial injuries. In studies evaluating full facial protection (FFP) versus half facial protection (HFP), FFP offered a significantly higher level of protection against facial injuries and lacerations than HFP (relative risk (RR) 2.31, CI 1.53 to 3.48). There was no significant difference in the rate of concussion (RR 0.97, CI 0.61 to 1.54) or neck injury (CI 0.43 to 3.16) between full and partial protection. In those who sustained concussion players with FFP returned to practice or games sooner than players with partial facial protection (PFP) (1.7 sessions, CI 1.32 to 2.18). Conclusions: There is good evidence that FFP reduces the number and risk of overall head and facial injuries in ice hockey compared with PFP and no facial protection. PFP, while not as protective as FFP, appears to offer more risk reduction than no protection.

Achilles tendon disorders

#### Summary points Disorders of the Achilles tendon are common in active people—competitive and recreational athletes alike—but they can occur in less active people. As the largest tendon in the body, the Achilles experiences repetitive strain from running, jumping, and sudden acceleration or deceleration, so is susceptible to rupture and degenerative changes. This review aims to describe the anatomy and diagnostic evaluation of the Achilles tendon, and to discuss the best available evidence to help in the management of Achilles tendon disorders. #### Sources and selection criteria We searched Medline (to include the Cochrane database) with the terms tendinopathy, Achilles tendon, tendon injuries, and Achilles tendon disorders. This was further limited to Achilles and finally to English language, human subjects within the past five years, and randomized controlled trials or evidence based reviews. The search yielded 70 references. We reviewed the abstracts of these 70 references and 57 met the inclusion criteria. Further landmark studies were added. The Achilles tendon is the strongest tendon in the body,1 serving both the gastrocnemius and soleus muscles. It begins near the mid-calf and inserts posteriorly at the calcaneus (fig 1⇓). In the region where the tendon joins the bone, there is an amalgam called the enthesis organ, in which the tissue is a composite of bone and tendon.2 Kager’s fat pad is located anterior to the Achilles tendon and posterior to the calcaneus, forms the superior border of this enthesis …