Evaluation of ECG abnormalities in athletes
| ECG abnormality | Potential cardiac disease* | Recommended evaluation† | Considerations |
|---|---|---|---|
| T wave inversion in the lateral or inferolateral leads | HCM DCM LVNC ARVC (with predominant left ventricular involvement) Myocarditis | Echocardiogram Cardiac MRI Exercise ECG test Minimum 24 hours ECG monitor | Lateral or inferolateral T wave inversion is common in primary myocardial disease. Cardiac MRI should be a routine diagnostic test for this ECG phenotype and is superior to echocardiography for detecting apical HCM, left ventricular hypertrophy localised to the free lateral wall, ARVC with predominant left ventricular involvement and myocarditis. If cardiac MRI is not available, echocardiography with contrast should be considered as an alternative investigation for apical HCM in patients with deep T wave inversion in leads V5-V6. Consider family evaluation if available and genetic screening. Annual follow-up testing is recommended throughout athletic career in athletes with normal results. |
| T wave inversion isolated to the inferior leads | HCM DCM LVNC Myocarditis | Echocardiogram | Consider cardiac MRI based on echocardiogram findings or clinical suspicion. |
| T wave inversion in the anterior leads‡ | ARVC DCM | Echocardiogram Cardiac MRI Exercise ECG test Minimum 24 hours ECG monitor Signal averaged ECG | The extent of investigations may vary based on clinical suspicion for ARVC and results from initial testing. |
| ST segment depression | HCM DCM LVNC ARVC Myocarditis | Echocardiogram | Consider cardiac MRI and additional testing based on echocardiogram findings or clinical suspicion. |
| Pathological Q waves | HCM DCM LVNC Myocarditis Prior myocardial infarction | Echocardiogram Coronary artery disease risk factor assessment Repeat ECG for septal (V1-V2) QS pattern; above investigations recommended if septal Q waves are persistent | Consider cardiac MRI (with perfusion study if available) based on echocardiogram findings or clinical suspicion. In the absence of cardiac MRI, consider exercise stress testing, dobutamine stress echocardiogram or a myocardial perfusion scan for evaluation of coronary artery disease in athletes with suspicion of prior myocardial infarction or multiple risk factors for coronary artery disease. |
| Complete left bundle branch block | DCM HCM LVNC Sarcoidosis Myocarditis | Echocardiogram Cardiac MRI (with stress perfusion study)§ | A comprehensive cardiac evaluation to rule out myocardial disease should be considered. |
| Profound non-specific intraventricular conduction delay ≥140 ms | DCM HCM LVNC | Echocardiogram | Consider additional testing based on echocardiogram findings or clinical suspicion. |
| Epsilon wave | ARVC | Echocardiogram Cardiac MRI Exercise ECG test Minimum 24 hours ECG monitor Signal averaged ECG | An epsilon wave in leads V1-V3 is a highly specific ECG maker and a major diagnostic criterion for ARVC. |
| Multiple premature ventricular contractions | HCM DCM LVNC ARVC Myocarditis Sarcoidosis | Echocardiogram 24 hours ECG monitor Exercise ECG test | If >2000 PVCs or non-sustained ventricular tachycardia are present on initial testing, comprehensive cardiac testing inclusive of cardiac MRI is warranted to investigate for myocardial disease. Consider signal averaged ECG. |
| Ventricular pre-excitation | Wolff-Parkinson-White | Exercise ECG test Echocardiogram | Abrupt cessation of the delta wave (pre-excitation) on exercise ECG denotes a low-risk pathway. Electrophysiological study for risk assessment should be considered if a low-risk accessory pathway cannot be confirmed by non-invasive testing. Consider electrophysiology study for moderate to high intensity sports. |
| Prolonged QTc | Long QT syndrome | Repeat resting ECG on separate day Review for QT prolonging medication Acquire ECG of first-degree relatives if possible | Consider exercise ECG test, laboratory (electrolyte) screening, family screening and genetic testing when clinical suspicion is high. Consider direct referral to a heart rhythm specialist or sports cardiologist for a QTc ≥500 ms. |
| Brugada type 1 pattern | Brugada syndrome | Referral to cardiologist or heart rhythm specialist | Consider high precordial lead ECG with leads V1 and V2 in second intercostal space or sodium channel blockade if Brugada pattern is indeterminate. Consider genetic testing and family screening. |
| Profound sinus bradycardia <30 beats per minute | Myocardial or electrical disease | Repeat ECG after mild aerobic activity | Consider additional testing based on clinical suspicion. |
| Profound 1° atrioventricular block ≥400 ms | Myocardial or electrical disease | Repeat ECG after mild aerobic activity Exercise ECG test | Consider additional testing based on clinical suspicion. |
| Advanced 2° or 3° atrioventricular block | Myocardial or electrical disease | Echocardiogram Minimum 24 hours ECG monitor Exercise ECG test | Consider laboratory screening and cardiac MRI based on echocardiogram findings. |
| Atrial tachyarrhythmias | Myocardial or electrical disease | Echocardiogram Minimum 24 hours ECG monitor Exercise ECG test | Consider cardiac MRI or electrophysiology study based on clinical suspicion. |
| Ventricular arrhythmias¶ | Myocardial or electrical disease | Echocardiogram Cardiac MRI Minimum 24 hours ECG monitor Exercise ECG test | A comprehensive cardiac evaluation to rule out myocardial disease and primary electrical disease should be considered. |
| Two or more borderline ECG findings | Myocardial disease | Echocardiogram | Consider additional testing based on clinical suspicion. |
* This list of disorders for each ECG abnormality represents the primary cardiac disorders of concern and is not intended to be exhaustive.
†Initial evaluation of ECG abnormalities should be performed under the direction of a cardiologist. Additional testing will be guided by initial findings and clinical suspicion based on the presence of symptoms or a family history of inherited cardiac disease or sudden cardiac death.
‡Excludes black athlete repolarisation variant and juvenile pattern in adolescents ≤16 years.
CT §coronary angiography if stress perfusion with cardiac MRI is unavailable.
¶Includes couplets, triplets, accelerated ventricular rhythm and non-sustained ventricular tachycardia.
ARVC, arrhythmogenic right ventricular cardiomyopathy; DCM, dilated cardiomyopathy; HCM, hypertrophic cardiomyopathy; LVNC, left ventricular non-compaction.