title: Clinical Differentiation Between Physiological Remodeling and Arrhythmogenic Right Ventricular Cardiomyopathy in Athletes With Marked Electrocardiographic Repolarization Anomalies.
abstract: BACKGROUND
  Physiological cardiac adaptation to regular exercise, including biventricular dilation and T-wave inversion (TWI), may create diagnostic overlap with arrhythmogenic right ventricular cardiomyopathy (ARVC).
  
  
  OBJECTIVE
  The goal of this study was to assess the accuracy of diagnostic criteria for ARVC when applied to athletes exhibiting electrocardiographic TWI and to identify discriminators between physiology and disease.
  
  
  METHODS
  The study population consisted of athletes with TWI (n = 45), athletes without TWI (n = 35), and ARVC patients (n = 35). Subjects underwent electrocardiography (ECG), signal-averaged electrocardiography (SAECG), echocardiography, cardiac magnetic resonance imaging (CMRI), Holter monitoring, and exercise testing.
  
  
  RESULTS
  There were no electrical, structural, or functional cardiac differences between athletes exhibiting TWI and athletes without TWI. When athletes were compared with ARVC patients, markers of physiological remodeling included early repolarization, biphasic TWI, voltage criteria for right ventricular (RV) or left ventricular hypertrophy, and symmetrical cardiac enlargement. Indicators of RV pathology included the following: syncope; Q waves or precordial QRS amplitudes <1.8 mV; 3 abnormal SAECG parameters; delayed gadolinium enhancement, RV ejection fraction ≤45%, or wall motion abnormalities at CMRI; >1,000 ventricular extrasystoles (or >500 non-RV outflow tract) per 24 h; and symptoms, ventricular tachyarrhythmias, or attenuated blood pressure response during exercise. Nonspecific parameters included the following: prolonged QRS terminal activation; ≤2 abnormal SAECG parameters; RV dilation without wall motion abnormalities; RV outflow tract ectopy; and exercise-induced T-wave pseudonormalization.
  
  
  CONCLUSIONS
  TWI and balanced biventricular dilation are likely to represent benign manifestations of training in asymptomatic athletes without relevant family history. Diagnostic criteria for ARVC are nonspecific in such individuals. Comprehensive testing using widely available techniques can effectively differentiate borderline cases.
authors.affiliation: St. George's University of London, London, United Kingdom.
authors.forename: Abbas
authors.initials: A
authors.lastname: Zaidi
authors.affiliation: St. George's University of London, London, United Kingdom.
authors.forename: Nabeel
authors.initials: N
authors.lastname: Sheikh
authors.affiliation: Isala Clinics, Zwolle, the Netherlands.
authors.forename: Jesse K
authors.initials: JK
authors.lastname: Jongman
authors.affiliation: St. George's University of London, London, United Kingdom.
authors.forename: Sabiha
authors.initials: S
authors.lastname: Gati
authors.affiliation: Imperial College Healthcare National Health Service Trust, London, United Kingdom.
authors.forename: Vasileios F
authors.initials: VF
authors.lastname: Panoulas
authors.affiliation: Guy's and St. Thomas's Hospital, London, United Kingdom.
authors.forename: Gerald
authors.initials: G
authors.lastname: Carr-White
authors.affiliation: St. George's University of London, London, United Kingdom.
authors.forename: Michael
authors.initials: M
authors.lastname: Papadakis
authors.affiliation: St. George's University of London, London, United Kingdom.
authors.forename: Rajan
authors.initials: R
authors.lastname: Sharma
authors.affiliation: St. George's University of London, London, United Kingdom.
authors.forename: Elijah R
authors.initials: ER
authors.lastname: Behr
authors.affiliation: St. George's University of London, London, United Kingdom. Electronic address: sasharma@sgul.ac.uk.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Sharma
mesh_terms: D000222:Adaptation, Physiological; D000328:Adult; D019571:Arrhythmogenic Right Ventricular Dysplasia / Q000175:diagnosis*; D002311:Cardiomyopathy, Dilated / Q000175:diagnosis / Q000503:physiopathology; D003937:Diagnosis, Differential; D004452:Echocardiography; D004562:Electrocardiography; D015716:Electrocardiography, Ambulatory; D015444:Exercise; D005080:Exercise Test; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D013178:Sports Medicine; D020257:Ventricular Remodeling / Q000502:physiology*
keywords: diagnosis; electrocardiogram criteria; exercise; imaging