This symposium was organised by the Section of Sports Cardiology in the European Association of Cardiovascular Prevention and Rehabilitation (Chairmen Hans Bjørnstad, Bergen Norway and Mats Børjesson, Gothenburg, Sweden). Both Chairmen, and most of the speakers, have been involved in the European recommendations for the screening of athletes and eligibility for sports, in patients with heart disorders.
These recommendations were presented in the EHJ 2005, and more extensively in the EJCPR 2005-2006, after the initiatives of the “Working Group of Cardiac Rehabilitation and Exercise Physiology” (Study Group of Sports Cardiology) - with the formal collaboration of the Working Groups of; Arrhythmias, Congenital Heart Disease, Hypertension, Myocardial and Pericardial Disease, as well as Valvular Disease. The ESC recommendations on screenings have also been accepted by the IOC and FIFA.
The first speaker was Klaus-Peter Mellwig, Bad Oeynhausen, Germany on, “Usefulness of electrocardiogram in the screening of athletes”. According to the literature, the normal ECG in athletes is characterized by lower heart rate, significant prolongation of PQ and QTc, increased QRS amplitudes including Sokolow index, increased ST elevations and, T wave amplitudes (Bjørnstad, Cardiology 91). However, negative T waves in lateral precordial leads are rare (0, 5%). It should be noticed that this is data from Caucasians. T inversions is probably more frequent in athletes of African origin. ECG has been defined as a screening tool according to the European recommendations, and with abnormalities in the ECG or on clinical investigation (including family history), further investigations should be pursued (in first step echocardiography). It is the consensus among experts that the cost-effectiveness of finding athletes at risk is far better with this strategy than with only clinical examination or with adding echo as a routine examination (Corrado, EHJ 05).
The following talks were on diseases which can often be discovered by ECG screening:
“Identification and Risk Stratification of Brugada Syndrome”, was presented by Pietro Delise, Conegliano, Italy, who stated that only Brugada Type I pattern is pathognomonic of the disease, however Type II and Type III patterns are diagnostic when converted to the Type I pattern. A patient with definite Brugada Syndrome should not perform competitive sports and, should not be considered for ICD. In some cases with no certain diagnosis, genetic analysis may be helpful. However, almost 30% of cases can be identified by genotype. This method obviously has limitations.
“The long QT syndrome” was the topic of W. Haverkamp, Berlin, Germany. In this syndrome, several genotypes have been identified which can be helpful in the diagnosis. Type 1 is particularly vulnerable to exercise, Type 2 to noise, while Type 3 often occurs during the night. Patients with long QT syndromes are at special risk when swimming. However, physical and mental stress in general can induce arrhythmias, and competitive sports is not recommended when the diagnosis is clear.
The next talk was given by Hein Heidbuchel, Leuven, Belgium on, “How to stratify the risk of right ventricular arrhythmogenic cardiomyopathy”. This disease can also be often identified by an ECG, as negative T wave in V1-V3 is found in more than 50%. Often late potential and increased QT dispersion can also be demonstrated. As competitive sports is not recommended and ICD is often indicated, the distinction of the benign RVOT tachycardia is important, but may be difficult to determine.
“Identification and risk stratification in hypertrophic cardiomyopathy” was the topic of the final talk, given by Antonio Pelliccia, Rome, Italy. This is the most common cause of sudden death in young athletes with a prevalence of 2 per 1000, which is up to 10 times more than some of the other conditions discussed. The causes of death are often arrythmogenic. It is also advisory to test the blood pressure response to a work load. The effectiveness of screening has been demonstrated by the Italian experience, where no cases were found on echo after screening, and the number of sudden deaths due to HCM had dropped dramatically (Corrado, 1998). In this disease the ECG has a potential to reveal more than 90% with T wave inversions in precordial leads. The most common findings being the increased voltage and pathological Q waves.