M Papadakis

Ethnic Differences in Physiological Cardiac Adaptation to Intense Physical Exercise in Highly Trained Female Athletes

Background— Ethnicity is an important determinant of cardiovascular adaptation in athletes. Studies in black male athletes reveal a higher prevalence of electric repolarization and left ventricular hypertrophy than observed in white males; these frequently overlap with those observed in cardiomyopathy and have important implications in the preparticipation cardiac screening era. There are no reports on cardiac adaptation in highly trained black females, who comprise an increasing population of elite competitors. Methods and Results— Between 2004 and 2009, 240 nationally ranked black female athletes (mean age 21±4.6 years old) underwent 12-lead ECG and 2-dimensional echocardiography. The results were compared with 200 white female athletes of similar age and size participating in similar sports. Black athletes demonstrated greater left ventricular wall thickness (9.2±1.2 versus 8.6±1.2 mm, P<0.001) and left ventricular mass (187.2±42 versus 172.3±42 g, P=0.008) than white athletes. Eight black athletes (3%) exhibited a left ventricular wall thickness >11 mm (12 to 13 mm) compared with none of the white athletes. All athletes revealed normal indices of systolic and diastolic function. Black athletes exhibited a higher prevalence of T-wave inversions (14% versus 2%, P<0.001) and ST-segment elevation (11% versus 1%, P<0.001) than white athletes. Deep T-wave inversions (−0.2 mV) were observed only in black athletes and were confined to the anterior leads (V1 through V3). Conclusions— Systematic physical exercise in black female athletes is associated with greater left ventricular hypertrophy and higher prevalence of repolarization changes than in white female athletes of similar age and size participating in identical sporting disciplines. However, a maximal left ventricular wall thickness >13 mm or deep T-wave inversions in the inferior and lateral leads are rare and warrant further investigation.

Pre-participation cardiovascular evaluation for athletic participants to prevent sudden death: Position paper from the EHRA and the EACPR, branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE:

Pre-participation cardiovascular evaluation for athletic participants to prevent sudden death : Position paper from the EHRA and the EACPR, branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE

ESC criteria for ECG interpretation in athletes: better but not perfect

The sudden cardiac death (SCD) of an apparently healthy young person (<35 years) has a devastating impact on the family and peers. Poignant newspaper articles and video footage showing the athletic prowess of the youth, apparent epitome of health and circumstantial paradox send ripples of emotion within the lay community. Over 80% of all exercise-related SCDs in young athletes are attributed to inherited or congenital cardiovascular disorders.1 2 Most causes of SCD are identifiable during life and several therapeutic strategies are available to minimise the risk of a SCD. Whereas most health professionals are staunch advocates of protecting young athletes on humanitarian grounds, the feasibility of implementing preparticipation screening (PPS) for cardiac disease specifically is frequently met with resistance and remains a heavily debated subject. The low incidence of SCD in sport (1 in 50 000) and need for multiple investigations to identify all implicated disorder raise issues pertinent to cost-effectiveness and are a persistent ‘Achilles heel’ for proponents of PPS. Furthermore, athletic training is associated with electrocardiographic patterns that may resemble those seen in patients with incomplete or morphologically mild expressions of primary cardiomyopathies and ion channelopathies. These false-positive results raise concerns about unnecessary investigations, erroneous disqualification and psychological harm to the athlete. Conversely, SCDs in sport are highly visible, claiming young lives.3 There is general agreement that a form of cost-effective PPS should be implemented; however, the precise methodology is contested. Most European countries do not offer state-sponsored PPS. In the USA, the American Heart Association implemented a PPS programme in 1996 to identify serious cardiovascular disorders in high school and intercollegiate athletes through a 12-point health questionnaire and physical examination.4 The American approach appears …

Pre-participation cardiovascular evaluation for athletic participants to prevent sudden death: Position paper from the EHRA and the EACPR, branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE.

AMI : acute myocardial infarction ARVC : arrhythmogenic right ventricular cardiomyopathy BrS : Brugada syndrome CACS : coronary artery calcium score CAD : coronary artery disease ChD : Chagas heart disease CMR : cardiac magnetic resonance CPVT : catecholaminergic polymorphic ventricular tachycardia CTCA : computed tomography coronary angiography CV : cardiovascular DCM : dilated cardiomyopathy EAPCR : European Association for Cardiovascular Prevention and Rehabilitation HCM : hypertrophic cardiomyopathy LGE : late gadolinium enhancement LQTS : long QT syndrome LV/RV : left/right ventricle LVH : left ventricle hypertrophy NSVT : non-sustained ventricular tachycardia PPE : preparticipation evaluation PVC : premature ventricular contractions SCA/SCD : sudden cardiac arrest/death TTE : transthoracic echocardiography VF : ventricular fibrillation VT : ventricular tachycardia Sudden cardiac death (SCD) associated with athletic activity is a rare but devastating event. Victims are usually young and apparently healthy, and while many of these deaths remain unexplained, a substantial number of victims harbour an underlying and potentially detectable cardiovascular (CV) disease.1–4 The vast majority of these events are due to malignant tachyarrhythmias, usually ventricular fibrillation (VF) or ventricular tachycardia (VT) degenerating into ventricular fibrillation (VF), occurring in individuals with arrhythmogenic disorders (e.g. hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, channelopathies). Intensive exercise training and competitive sport participation is a trigger that may favour insurgence of ominous ventricular tachyarrhythmias in predisposed individuals.5 Consequently, there is a great interest in early identification of at-risk individuals for whom appropriate treatment, followed or not by physical activity adjustment, may be implemented to minimize the risk of SCD. However, the role of pre-participation evaluation (PPE) in athletes as a feasible and efficient strategy to identify individuals at risk has remained controversial. …

Unmasking of the Brugada phenotype during exercise testing and its association with ventricular arrhythmia on the recovery phase

Two largely asymptomatic men, a 36-year-old (patient A) and a 56-year-old (patient B), were evaluated following the sudden death of a first-degree relative. Both resting 12-lead electrocardiograms exhibited minor ST-segment elevation in V1 and 0.2 mV saddle-shaped ST-segment elevation in V2. During an exercise test, patient A developed 0.7 mV ST-segment elevation with coved pattern and T-wave inversion in V2 and ST-segment elevation and T-wave inversion in V3, at peak exertion …

063 Sex and ethnicity specific ECG differences in elite athletes: relevance to pre-participation cardiovascular evaluation: the British experience

Purpose The athletes ECG is affected by several demographic factors but there is a paucity of data relating to the impact of the athletes sex and ethnicity. The ESC guidelines for ECG interpretation in athletes are derived predominantly from male cohorts. Extrapolating such criteria to athletes of African/afro-Caribbean origin and female athletes may lead to erroneous interpretation. Methods Between 2001 and 2011, 1378 highly trained athletes (55% males, 81% Caucasian) (mean age 21.6±5.43 years); range 14–35 years, underwent cardiac evaluation including 12-ECG and echocardiography. ECGs were analysed for training related (group 1) and training-unrelated (group 2) changes, according to the ESC guidelines. Results Males demonstrated a higher prevalence of Group 1 (89% vs 61%; p=<0.0001) and Group 2 ECG changes (26% vs 16%; p=0.0001) compared with females. Of the group 1 changes, isolated left ventricular hypertrophy (42%), early repolarisation patterns (ST elevation >0.1 mV) (61%), first-degree AV block (10%) were more prevalent in males compared to 14%, 45% and 4.7% females respectively (p=0.0001). Of the group 2 changes, T-wave inversion in leads V1-V4 were more prevalent in female athletes (12%) particularly black females (17%) compared to male athletes (4%; p=0.0001), whereas, T-wave inversion in the inferior leads were more common in males (3.3% vs 0.6%) irrespective of ethnicity. Males demonstrated a higher prevalence of axis deviation (6.7% vs 2.1%; p=0.0001), atrial enlargement (4.2% vs 1.0%; p=0.0002) and right ventricular hypertrophy (RVH) (8.3% vs 2.6%; p=0.0001) compared with females. Caucasian athletes exhibited greater group 1 changes compared with black athletes (73% vs 65%; p=0.0161). Black athletes exhibited a higher prevalence of group 2 ECG changes compared with Caucasian athletes (34% vs 21%; p=<0.0001) with 15% of black athletes exhibiting T-wave inversion, 4.5% left atrial enlargement 14% right atrial enlargement and 12% demonstrating RVH compared to 9%, 0.9%, 0.09% and 4.1% of Caucasian athletes respectively. There was no correlation between any ECG parameter and cardiac chamber size. Conclusions Male sex and black ethnicity equated to a higher prevalence of Group 1 and 2 ECG changes compared with female sex and Caucasian ethnicity. However, anterior T wave inversion was significantly more common in females, being present in over 10% of athletes irrespective of ethnicity than previously reported. The precise incidence and significance of anterior T-wave inversion in female athletes requires further assessment.

149 Ethnic differences in performance of the 2010 European Society of Cardiology criteria for ECG interpretation in athletes

Background Physical activity is associated with ECG phenotypes that may overlap with those observed in conditions predisposing to sudden cardiac death. In 2005 the study group of sports cardiology produced guidelines to differentiate ECG changes likely to reflect physiological adaptation to exercise from those, which should prompt further investigations. The guidelines were updated in 2010 resulting in improved specificity in predominantly Caucasian cohorts (white athletes; WA). We sought to examine the performance of the 2010 guidelines in athletes of African/Afro-Caribbean origin (black athletes; BA). Methods ECG of 923 male BA were evaluated to determine the proportion of individuals requiring further investigations based on the 2005, compared to the updated 2010 guidelines. The same evaluation was performed for a cohort of 1711 male WA and 209 patients with hypertrophic cardiomyopathy (HCM). In addition, the impact of “Refined Criteria” was examined, consisting of an upper limit of 470 msec for QTc and removing the following as abnormalities: (1) isolated voltage criteria for left atrial enlargement (LAE); (2) Isolated voltage criteria for right ventricular hypertrophy (RVH); (3) T-wave inversions (TWI) in V1/2 in WA and V1-V4 in BA. Results Using 2005 guidelines, 549 BA (59.5%) met criteria for a positive ECG requiring referral for further investigations compared to 846 WA (49.4%). In comparison, 398 BA (43.1%) met criteria for a positive ECG using 2010 guidelines [predominantly due to TWI (22.3%), RVH (13.0%) and LAE 8.5%)] compared to 216 WA (12.6%) [predominantly due to TWI (3.0%), RVH (2.8%) and LAE (2.7%)]. All of the HCM patients met the criteria for a positive ECG, regardless of which guidelines were used. Using our “Refined Criteria,” the number of BA with a positive ECG was reduced to 161 (17.4%) and WA to 93 (5.4%). Five patients with HCM had isolated voltage criteria for LAE (2.4%); all were symptomatic apart from 1 (0.5%). Five patients with HCM had voltage criteria for LAE in combination with LVH but no other abnormalities on their ECG; all were symptomatic apart from 1 (0.5%). Conclusions Updated guidelines significantly reduce the number of positive ECG results in WA, but less so in BA, emphasising the need for ethnicity specific criteria to be developed. Refining criteria based on physiological changes known to occur in athletes heart results in further reduction in positive ECGs. Our findings in patients with HCM suggest that if found in isolation or in combination with voltage criteria for LVH alone, ECG evidence of LAE may be regarded as a physiological rather than pathological change.

072 Fragmented QRS: a predictor of myocardial scar and fibrosis in hypertrophic cardiomyopathy

Background It is well-established that fragmented QRS complexes (fQRS) on the 12-lead ECG are a predictor of delayed gadolinium enhancement (DGE) on Cardiac MRI (CMR) and indicate myocardial scar or fibrosis in patients with coronary artery disease and dilated cardiomyopathy. Moreover, fQRS appear to correlate well with arrhythmic events and mortality in these cohorts. However the significance of fQRS in hypertrophic cardiomyopathy (HCM) is yet to be established. We sought to determine whether the presence of fQRS is a predictor of delayed gadolinium enhancement (DGE) on CMR in patients with HCM. Methods The 12-lead ECGs of 82 consecutive patients with HCM who underwent CMR with gadolinium were analysed for the presence of fQRS by two independent readers blinded to the CMR findings. Patients with documented myocardial infarction (n=3) were excluded from further analysis. The ECGs were correlated to CMR findings, and patients separated into DGE positive (DGE+ve; n=44) and negative (DGE−ve; n=35) groups. ECG territories of fQRS were correlated with myocardial segments of DGE on CMR, in order to determine whether areas of fQRS predicted areas of DGE. Results Patients from the DGE+ve and DGE-ve groups were of similar gender (75% vs 77% male respectively, p=1.00) and age (54 ± 19 vs 57 ± 11 years respectively, p=0.41). Fragmented QRS complexes were significantly more prevalent in the DGE+ve group than in the DGE-ve group (68.2% vs 14.3%, p<0.001). The positive predictive value (PPV) of fQRS for DGE on CMR was 85.7%, with a specificity of 85.7%, sensitivity of 68.2% and negative predictive value of 68.2%. In the DGE+ve group with fQRS (n=30), fQRS ECG lead territory was predictive of regions of DGE on CMRI in 73.3% (n=22) of patients. Conclusions The presence of fQRS on 12-lead ECG correlates with DGE on CMR in patients with HCM, with good specificity and PPV. Electrocardiographic territories containing fragmentation also correlate with myocardial segments of DGE on CMR. This simple, inexpensive method may therefore be valuable for predicting scar or fibrosis in patients with HCM. Future work should focus on correlating fQRS with risk factors and events to determine its use in risk stratification.

170 Ethnic differences in phenotypic expression of hypertrophic cardiomyopathy

Purpose Hypertrophic Cardiomyopathy is a heterogeneous condition with variable phenotypic expression. Current studies are based on predominantly Caucasian cohorts (white patients; WP), therefore the phenotypic manifestations of HCM in individuals of African/Afro-Caribbean origin (black patients; BP) are not fully realised. Data in athletes and hypertensive patients indicate that black ethnicity is associated with a greater prevalence of repolarisation abnormalities on the ECG as well as a greater magnitude of left ventricular hypertrophy (LVH), highlighting the importance of defining the HCM phenotype in this ethnic group. Methods Between 2001 and 2010, 155 consecutive patients with HCM (52 BP, 103 WP) were assessed in 3 specialist cardiomyopathy clinics in South London. All individuals underwent comprehensive cardiac evaluation including 12-lead ECG and echocardiography. Patients subject to therapeutic interventions potentially affecting repolarisation patterns were excluded. Results Black patients revealed significantly different echocardiographic patterns of LVH, with more concentric (44.2% vs 30.1%) and apical (28.8% vs 11.7%) hypertrophy compared to WP who exhibited more asymmetric septal hypertrophy (57.3% vs 25.0%) (p=0.004). Black patients exhibited a similar magnitude of LVH compared to WP (17.3±4.9 vs 18.8±4.1 mm, p=0.069). Relating to ECG repolarisation abnormalities, BP exhibited more T wave inversions in the lateral leads (76.9% vs 60.2%, p=0.038) and deep (≥−0.2 mV) T-wave inversions (69.2% vs 51.5%, p=0.035). Black patients also tended to display more ST segment depression (50.0% vs 35.0%, p=0.071), although this was not statistically significant. In contrast, WP had significantly more pathological Q waves (23.3% vs 9.6%, p=0.039). Conclusions Ethnicity appears to exert a significant effect on ECG and echocardiographic patterns in patients with HCM. A significant proportion of black patients exhibit concentric LVH, highlighting the diagnostic challenges in distinguishing HCM from hypertensive heart disease and physiological adaptation to exercise in black individuals. The greater prevalence of deep T wave inversions and T wave inversions in the lateral leads underscores the importance of further evaluation of black individuals with such ECG repolarisation abnormalities, which may represent the initial expression of HCM.Abstract 170 Table 1 Black HCM (n=52) white HCM (n=103) p Value Demographics Age of diagnosis (years) 48.1±17.1 50.5±16.5 0.552 Gender (males) 61.5% 62.1% 0.942 FH of HCM/SCD 34.6% 32.0% 0.747 NYHA functional class III or IV 7.7% 7.8% 0.987 Patients on treatment 55.8% 46.6% 0.281  B-blockers 28.8% 39.1% 0.445  Calcium antagonists 26.9% 12.6% 0.026  Amiodarone 7.7% 1.9% 0.080  Diuretics 13.5% 9.7% 0.480  Disopyramide 3.8% 9.7% 0.197 Intracardiac defibrillator in situ 5.8% 5.8% 0.989 Echocanliographic characteristics Ao (mm) 31.3±3.7 33.2±5.8 0.123 LA (mm) 40.9±7.3 39.9±7.3 0.593 LVED (mm) 44.0±6.1 44.4±6.1 0.787 mLVWTd (mm) 17.3±4.9 18.8±4.1 0.069 LV mass (g) 279.6±106.5 287.6±112.7 0.767 FS (%) 40.4±9.1 39.8±8.3 0.641 E wave (m/s) 0.70±0.18 0.74±0.20 0.443 A wave (m/s) 0.67±0.18 0.66±0.27 0.851 E/A 1.11±0.44 1.22±0.58 0.422 SAM 23.1% 37.9% 0.064 LVOT gradient = 30 mm Hg 23.1% 34.0% 0.163 LVH pattern  ASH 25% 57.3% 0.004  Concentric 44.2% 30.1%  Apical 28.8% 11.7%  No hypertrophy 1.9% 1.0% Echocanliographic characteristics LVH (Sokolow & Lyon) 53.8% 35.9% 0.033 Left atrial enlargement 44.2% 49.5% 0.534 Pathological Q waves 9.6% 23.3% 0.039 Left axis deviation 11.5% 17.2% 0.270 Inverted T-waves 82.7% 69.9% 0.086 T-wave inversions in V1–V4 3.8% 3.9% 0.991 T-wave inversions in inferior leads 1.9% 5.8% 0.269 T-wave inversions in lateral leads 76.9% 60.2% 0.038 Deep T-wave inversions 69.2% 51.5% 0.035 ST-segment elevation 9.6% 9.7% 0.985 ST-segment depression 50% 35.0% 0.071

50 Diagnostic role of exercise tolerance testing in familial premature sudden cardiac death

Background Investigation of blood relatives for evidence of an inherited cardiac condition is advocated following an unexplained sudden cardiac death (SCD). Aim We determined the diagnostic yield of exercise tolerance testing (ETT) in investigation of inherited cardiac conditions following familial premature SCD. Methods Between 2006 and 2010, we evaluated 308 blood relatives of 148 SCD victims, who completed at least 3 min of the Bruce protocol. ETTs were analysed for: QT prolongation; Brugada type 1 pattern; ST depression: blood pressure (BP) response; multiple ventricular ectopics or arrhythmia. Individual pathological phenotypes were determined by a combination of 12-lead ECG, echocardiogram, 24-h holter monitor, with additional MRI, CT coronary angiography and genetic mutation analysis, as appropriate. Results Thirty (9.8%) patients had an abnormality during ETT, details of which are summarised in Abstract 50 figure 1. All ETTs with abnormal QT prolongation and dynamic Brugada pattern were associated with diagnoses of long QT syndrome and Brugada syndrome respectively. An example of dynamic Brugada phenotype is given in Abstract 50 figure 2. Ventricular ectopy was seen in 15 patients, of whom 5 demonstrated phenotypic cardiomyopathy or channelopathy on further investigations. No patients with significant ST depression had evidence of coronary abnormalities on imaging. No hypotensive BP response was seen, but exertional hypertension was associated with systemic hypertension.Abstract 50 Figure 1 ETT abnormalities and associated diagnoses at familial evaluation.Abstract 50 Figure 2 Exercise tolerance test demonstrating dynamic Brugada ECG pattern. Stage 1 of Bruce protocol exercise (left) and post-exercise recovery (right). Conclusion The ETT is a useful diagnostic adjunct when evaluating relatives of victims of premature SCD. Reliable diagnostic indicators include inappropriate QT prolongation and dynamic Brugada pattern. Ventricular ectopy is non-specific, but is associated with both cardiomyopathic and channelopathic processes in a significant minority. ST segment depression, however, is unhelpful and should be viewed in the context of the patients cardiovascular risk profile.