Should axis deviation or atrial enlargement be categorised as abnormal in young athletes? The athlete's electrocardiogram: time for re-appraisal of markers of pathology.
OBJECTIVE
The 2010 European Society of Cardiology (ESC) guidelines for electrocardiogram (ECG) interpretation in athletes are associated with a relatively high false positive rate and warrant modification to improve the specificity without compromising sensitivity. The aim of this study was to investigate whether non-specific anomalies such as axis deviation and atrial enlargement in isolation require further assessment in highly trained young athletes.


RESULTS
Between 2003 and 2011, 2533 athletes aged 14-35 years were investigated with 12-lead ECG and echocardiography. Electrocardiograms were analysed for non-training-related (Group 2) changes according to the 2010 ESC guidelines. Results were compared with 9997 asymptomatic controls. Of the 2533 athletes, 329 (13%) showed Group 2 ECG changes. Isolated axis deviation and isolated atrial enlargement comprised 42.6% of all Group 2 changes. Athletes revealed a slightly higher prevalence of these anomalies compared with controls (5.5 vs. 4.4%; P = 0.023). Echocardiographic evaluation of athletes and controls with isolated axis deviation or atrial enlargement (n = 579) failed to identify any major structural or functional abnormalities. Exclusion of axis deviation or atrial enlargement reduced the false positive rate from 13 to 7.5% and improved specificity from 90 to 94% with a minimal reduction in sensitivity (91-89.5%).


CONCLUSIONS
Isolated axis deviation and atrial enlargement comprise a high burden of Group 2 changes in athletes and do not predict underlying structural cardiac disease. Exclusion of these anomalies from current ESC guidelines would improve specificity and cost-effectiveness of pre-participation screening with ECG.
St George's University of London, Cranmer Terrace, SW17 0RE, London SE5 9RS, UK.
Sabiha
S
Gati
Nabeel
N
Sheikh
Saqib
S
Ghani
Abbas
A
Zaidi
Mathew
M
Wilson
Hariharan
H
Raju
Andrew
A
Cox
Matt
M
Reed
Michael
M
Papadakis
Sanjay
S
Sharma
D000293:Adolescent; D000328:Adult; D006332:Cardiomegaly / Q000191:economics / Q000473:pathology* / Q000503:physiopathology; D059267:Cardiomegaly, Exercise-Induced / Q000502:physiology; D002312:Cardiomyopathy, Hypertrophic / Q000191:economics / Q000473:pathology / Q000503:physiopathology; D016022:Case-Control Studies; D003362:Cost-Benefit Analysis; D003430:Cross-Sectional Studies; D042241:Early Diagnosis; D004562:Electrocardiography / Q000191:economics / Q000379:methods; D005260:Female; D006325:Heart Atria / Q000473:pathology; D006801:Humans; D008297:Male; D013177:Sports / Q000502:physiology*; D055815:Young Adult
Athlete's Heart; Electrocardiogram; Pre-participation screening