Clinical Differentiation Between Physiological Remodeling and Arrhythmogenic Right Ventricular Cardiomyopathy in Athletes With Marked Electrocardiographic Repolarization Anomalies.

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). OBJECTIVES: 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.

Relationship between echocardiographic right-ventricular dimensions and signal-averaged electrocardiogram abnormalities in endurance athletes.

AIMS: Regular physical exercise results in physiological cardiovascular changes. Athletes may demonstrate electrocardiographic changes that can also be seen in certain cardiomyopathies such as arrhythmogenic right-ventricular cardiomyopathy (ARVC). The aim of this study was to assess the prevalence of one such electrocardiographic characteristic, the abnormal signal-averaged ECG (SAECG), and to assess the correlation between SAECG parameters and echocardiographic parameters in athletes participating in sporting disciplines with combined strength and endurance components. METHODS AND RESULTS: We evaluated 24 elite athletes and 27 amateur athletes participating in combined high dynamic and high static (HDHS) sports, using an ECG, SAECG, and a transthoracic echocardiogram. The SAECG was regarded as positive for late potentials if one out of three parameters was abnormal. Prolongation of the filtered QRS duration (fQRS) was present in all of the elite athletes, compared with 74.1% of the amateur athletes (P = 0.011). There was a low prevalence of abnormalities in the other two SAECG parameters [low-amplitude signal (LAS) duration and root-mean-square (RMS) voltage]. The percentage of elite athletes and amateur athletes with ≥2 abnormal SAECG parameters was 8.3 and 7.4% (P = 0.99), respectively. Most of the echocardiographic dimensions were significantly greater in the elite athlete group compared with the amateur athletes. There was a moderate positive correlation between the fQRS and right-ventricular dimensions. CONCLUSION: The majority of elite and amateur athletes participating in HDHS sports reveal a prolonged fQRS duration on the SAECG, and according to the 2010 Task Force criteria for the diagnosis of ARVC, these athletes therefore demonstrate late potentials. The extent of fQRS prolongation is positively correlated with RV dimensions. Therefore SAECG findings should be interpreted with caution in endurance athletes.

Performance of the Lausanne questionnaire and the 2010 European Society of Cardiology criteria for ECG interpretation in athletes.

BACKGROUND: In recent years various proposals and subsequent changes have been made to improve pre-participation screening (PPS) methods. This study examines the Lausanne questionnaire and the old and new ESC criteria for a positive electrocardiogram (ECG) in athletes. DESIGN: Retrospective cohort study. METHODS: All consecutive students undergoing a PPS between January and July 2011 were included. The screening consisted of the Lausanne questionnaire, a physical examination, and a 12-lead ECG. RESULTS: A total of 561 students were screened. A total of 310 students (55%) answered positively to one or more of the Lausanne questions and 49 (9%) of these abnormalities were assessed as medically relevant. Physical examination was abnormal in nine (1.6%) students. In total, 120 (21%) ECGs were found positive following the old criteria. According to the new criteria, 68 (12%) ECGs were found positive. Four (already known) congenital cardiac disorders and four new diagnoses were found. When using the new ECG criteria, two out of four new cardiovascular diagnoses would have been missed. CONCLUSIONS: The use of the Lausanne questionnaire provides many irrelevant findings causing unnecessary positive screening outcomes. With the new ESC criteria for a positive 12-lead ECG in athletes, the number of false-positive screenings greatly decrease: however, at the cost of an increase in the number of false-negatives. To reach a conclusive judgment on the cost:benefit ratio of PPS, it is necessary to have a validated discriminating questionnaire, specific medical knowledge of PPS and clear definitions of a normal and abnormal 12-lead ECG in athletes.

[Takotsubo cardiomyopathy; reversible cardiomyopathy induced by stress]. / Viskruikinfarct. Reversibele cardiomyopathie door stressvolle gebeurtenis.

Takotsubo cardiomyopathy was diagnosed in a 79-year-old woman. She visited her husband who had been admitted for primary percutaneous coronary intervention, and during her visit she developed acute chest pain. Further investigation revealed transient left ventricular apical ballooning, diagnosed as takotsubo cardiomyopathy. This clinical syndrome is characterized by transient regional left ventricle wall motion abnormalities without significant epicardial coronary stenosis. It is provoked by stressful events. Especially in elderly women presenting with the clinical features of an ST-elevation myocardial infarction, takotsubo cardiomyopathy should be considered as an alternative diagnosis. Regarding the exact aetiology and pathophysiology many questions remain unanswered. With supportive treatment the prognosis is favourable.