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A 22-year-old female athlete with premature ventricular beats

Sabiha Gati, Sports Cardiology Quiz Section Editor

Background:
This case demonstrates the challenges of interpreting ventricular arrhythmias in asymptomatic athletes. Premature ventricular contractions (PVCs) can occur during normal daily life. Less than 1% of PVCs are seen on Holter assessment and these can increase with age. A minority of athletes may exhibit frequent or complex ventricular arrhythmias with a prevalence similar to sedentary counterparts. However, PVCs may be a marker of underlying heart disease even in asymptomatic individuals. It is important to pay attention to the characteristics of the PVCs including morphology, complexity, multifocal origin, and/or increasing frequency with exercise that may provide clues to an underlying electrical, ischaemic or structural change that may be associated with sudden cardiac death.

Sports Cardiology


The case

22-year-old female competitive tennis player was referred for cardiovascular screening. She was asymptomatic from a cardiovascular perspective and trained during three sessions per week for a duration of approximately 5-6 hours.

There is a family history of sudden cardiac death (father died suddenly at the age of 35 years). Clinical examination demonstrated a heart rate of 40bpm regular with a BP of 110/60mmHg. Cardiac auscultation revealed dual heart sounds with no additional murmurs.

Cardiac investigations:

  • The 12-lead electrocardiogram (ECG) is shown in Figure 1
  • Echocardiography was performed (Videos 1 & 2)
  • On exercise treadmill testing, there was 1 premature ventricular contraction (PVC) at peak of exercise and 3 PVCs during the early recovery with 2 different morphologies (RBBB, wide QRS+superior axis and LBBB+inferior axis), shown in Figure 2
  • A 24-hour Holter ECG revealed isolated ventricular extra-systoles (54/24 h, same morphologies of PVCs seen at treadmill test)

Figure 1. Resting ECG

2019-12-quiz7-Figure-1.JPG

 

Video 1. Echocardiography, parasternal long axis view

Video 2. Echocardiography, subcostal view

Figure 2. ECG during exercise stress test

Showing premature ventricular complexes (RBBB, wide QRS+superior axis):

2019-12-quiz7-Figure-2.JPG

 

 

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Note: The views and opinions expressed on this page are those of the author and may not be accepted by others. While every attempt is made to keep the information up to date, there is always going to be a lag in updating information. The reader is encouraged to read this in conjunction with appropriate ESC Guidelines. The material on this page is for educational purposes and is not for use as a definitive management strategy in the care of patients. Quiz material in the site are only examples and do not guarantee outcomes from formal examinations.

References

Kennedy HL, Whitlock JA, Sprague MK, Kennedy LJ, Buckingham TA, Goldberg RJ. Long-term follow-up of asymptomatic healthy subjects with frequent and complex ventricular ectopy. N Engl J Med 1985;312(4):193-7.

von Rotz M, Aeschbacher S, Bossard M, Schoen T, Blum S, Schneider S, Estis J, Todd J, Risch M, Risch L, Conen D. Risk factors for premature ventricular contractions in young and healthy adults. Heart 2017;103(9):702-707.

Biffi A, Pelliccia A, Verdile L, Fernando F, Spataro A, Caselli S, Santini M, Maron BJ. Long-term clinical significance of frequent and complex ventricular tachyarrhythmias in trained athletes. J Am Coll Cardiol 2002;40(3):446-52.

Palatini P, Maraglino G, Sperti G, Calzavara A, Libardoni M, Pessina AC, Dal Palu C. Prevalence and possible mechanisms of ventricular arrhythmias in athletes. Am Heart J 1985;110(3):560-7.

Lee V, Perera D, Lambiase P. Prognostic significance of exercise-induced premature ventricular complexes: a systematic review and meta-analysis of observational studies. Heart Asia 2017;9(1):14-24.

Lin CY, Chang SL, Chung FP, Chen YY, Lin YJ, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Chang YT, Lin CH, Allamsetty S, Walia R, Te AL, Yamada S, Chiang SJ, Tsao HM, Chen SA. Long-Term Outcome of Non-Sustained Ventricular Tachycardia in Structurally Normal Hearts. PLoS One 2016;11(8):e0160181.

Notes to editor

Author information:

Flavio D’Ascenzi, MD, PhD, FESC*; Francesca Anselmi, MD*; Sergio Mondillo, MD*; Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy