Physician adherence to 'Seattle' and 'International' ECG criteria in adolescent athletes: An analysis of compliance by specialty, experience, and practice environment.

BACKGROUND: Screening electrocardiography (ECG) for athletes is both controversial and rapidly evolving. While identifying an abnormal ECG could detect a serious cardiovascular disease, falsely interpreting a benign ECG pattern as abnormal can lead to unnecessary testing, cost, and anxiety. Though recent refinements of athlete screening ECG criteria have significantly improved its accuracy, in clinical practice physician adherence to these criteria may vary. METHODS: We analyzed physician adherence to contemporary athlete ECG criteria in a large, national athlete screening registry. 1577 consecutive screening ECGs were independently re- interpreted to assess for physician adherence to Seattle Criteria or International Criteria, respective to the criteria in place when the screening was performed. We further determined the most common ECG interpretations that deviated from these criteria, and analyzed physician characteristics for independent predictors of adherence to published ECG criteria. RESULTS: Though overall adherence to contemporary criteria was high, 60.4% of ECGs interpreted as abnormal did not meet athlete ECG criteria for pathology when independently re- read. The most common ECG patterns misinterpreted as abnormal were isolated left ventricular hypertrophy (LVH) and non-pathologic T-wave inversions (TWI). Multivariate regression identified three independent predictors of adherence to athlete ECG criteria: participating in a screening overseen by the organization's medical leadership, electrophysiology specialists and adult cardiologists. CONCLUSION: This study highlights the need for quality control measures and continued clinician education in a controversial and rapidly evolving field. Clinician education for athlete screening ECG criteria should emphasize the recent changes in how TWI and LVH voltage criteria should be interpreted in this patient population.

International recommendations for electrocardiographic interpretation in athletes.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

International criteria for electrocardiographic interpretation in athletes: Consensus statement.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

High Prevalence of Obesity and High Blood Pressure in Urban Student-Athletes.

OBJECTIVES: To assess the prevalence of obesity and hypertension-level blood pressures in an urban, athletic adolescent population using preparticipation physical evaluation (PPE) data. STUDY DESIGN: The Athlete Health Organization provides free preparticipation physical evaluations to Philadelphia student-athletes via an annual mass-screening event. From 2009 to 2012, Athlete Health Organization personnel performed PPEs on more than 2700 middle school and high school athletes. The PPE included biometric information, a history, and a physical examination. Medical volunteers measured blood pressures using a manual blood pressure cuff with an aneroid manometer. The data from each PPE were collected and analyzed for prevalence of obesity, overweight, and hypertension-level blood pressure readings. RESULTS: A large percentage of student-athletes were found to be overweight (20%) or obese (24.0%). Many of these athletes also had stage 1 or 2 level blood pressure readings (14.8%), a finding which strongly correlated with elevated body mass index (P < .00001). CONCLUSIONS: The cardiovascular health of this urban adolescent athletic population is a major concern because their rates of obesity and elevated blood pressure place them at increased risk of cardiovascular complications later in life despite their participation in school athletics.

Relationship Between Caffeine Consumption and Young Athletes' Comorbidities, Exercise-Related Symptoms, and Baseline Electrocardiogram.

BACKGROUND: Caffeine consumption causes diverse physiologic effects that can affect athletes both positively and negatively. There is a lack of research investigating the long-term effects of caffeine intake on exercise and on overall cardiovascular health in young athletes. HYPOTHESIS: Certain characteristics such as age, body mass index (BMI), race, and medical diagnoses are associated with increased caffeine use, and there is a relationship between caffeine consumption and symptoms during exercise and cardiovascular abnormalities in young athletes. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 4. METHODS: This study utilized the HeartBytes National Youth Cardiac Registry to collect data related to demographics, caffeine use, and physical examination and electrocardiogram (ECG) findings of 7425 12- to 20-year-olds (60.6% male, 39.4% female) who attended a Simon's Heart cardiac screening event between 2014 and 2021. Univariable and multivariable logistic regression models were used for analysis. RESULTS: Persons who consumed caffeine were more likely to have attention deficit hyperactivity disorder (ADHD) (adjusted odds ratio [aOR], 1.43; CI, 1.15-1.76]; P < 0.01) and more likely to have a BMI ≥30 kg/m2 (aOR, 1.69; CI, 1.27-2.25]; P < 0.01) compared with nondrinkers. After controlling for age, gender, race, and BMI, there were no significant differences in symptoms during exercise (aOR, 1.27; CI, 0.97-1.66; P = 0.08) or abnormal ECG findings (OR, 0.93; CI, 0.66-1.31; P = 0.70) between those who consume caffeine and those who do not. CONCLUSION: Caffeine consumption was associated with increased BMI and increased likelihood of having ADHD; however, caffeine use overall was not associated with increased risk of symptoms during exercise or ECG abnormalities. CLINICAL RELEVANCE: Whereas caffeine consumption overall did not increase risk of exercise-related symptoms, soda drinkers were at higher risk for symptoms during exercise, and coffee drinkers were at higher risk of syncope with exercise. Prospective studies with longitudinal follow-up and more specific outcomes data is the next step in qualifying the impact of caffeine on young athletes.

Relationship Between Obesity and Youth Athletes' Physical Activity and Exercise-Related Cardiac Symptoms.

Background: While studies have identified the negative cardiovascular effects of obesity, the effects of obesity on youth athletes are less studied. This study investigates the associations between obesity in youth athletes and exercise activity and exertional cardiac symptoms. Methods: The HeartBytes National Youth Database produced by Simon's Heart, a nonprofit that organizes adolescents' sports pre-participation examinations (PPEs), was used. This database contains demographic data, exercise-related symptoms, and electrocardiogram data obtained during PPEs. BMI was converted to percentiles, with obesity defined as BMI ≥95th percentile. Outcomes were evaluated using a chi-squared test with odds ratios (ORs) and 95% confidence intervals (CIs). Results: Of 7363 patients, there were 634 individuals with obesity. Youth athletes within normal weight ranges (5th-85th percentile) had higher exercise rates than those with underweight, overweight, or obesity (p < 0.001 for each). Athletes with obesity had higher odds of exertional symptoms overall (OR: 1.63 [CI: 1.36-1.96]; p < 0.001). However, for athletes who exercised >10 hours a week, there was no association between obesity and exertional symptoms. Athletes with obesity had higher odds of elevated blood pressure (OR: 5.35 [CI: 2.00-14.30]; p < 0.001) and hypercholesterolemia (OR: 3.84 [CI: 2.51-5.86]; p < 0.001). Conclusions: In this dataset, obesity in youth athletes is associated with decreased physical activity and increased exertional symptoms in general. Obesity is not associated with exertional symptoms in athletes who participated in higher weekly physical activity. Further studies are needed to elucidate the cause-effect relationship of these findings.

Parameters of cardiac symptoms in young athletes using the Heartbytes database.

Introduction: To determine clinical parameters that are related to abnormal cardiac symptoms in physically active youth. Methods: We used Simon's Heart Heartbytes National Youth Cardiac Registry to collect data from adolescent athletes in southeastern Pennsylvania. We collected age, race/ethnicity, abnormal cardiac symptoms, medical history, medication use, caffeine intake, and family history. We obtained height, weight, blood pressure, cardiac murmur findings, and ECGs. Echocardiogram was obtained if necessary. Binary logistic regression analysis was performed to identify independent associations between abnormal cardiac symptoms and collected variables. The odds ratio (OR), 95% confidence interval (95% CI), and p-values were used as statistical values. Results: Of the 887 athletes (543 males and 344 females, age = 16.9 ± 2.1 years, height = 166.9 ± 11.4 cm, weight = 62.0 ± 16.0 kg), 186 (21%) had abnormal cardiac symptoms including chest pain, passing out, difficulty breathing, extreme fatigue, and heart race. There was an independent association between abnormal symptoms and a past medical history (OR: 4.77, 95%CI: 3.18, 7.17, p = 0.001) and medication use (OR: 1.74, 95%CI: 1.08, 2.79, p = 0.022). In medical history, young athletes with asthma showed a greater propensity of abnormal cardiac symptoms (48.9%) compared to young athletes without (14.0%, p = 0.001). Additionally, young athletes with anxiety or depression demonstrated a higher proportion of abnormal cardiac symptoms (48.9%) than those without (19.5%, p = 0.001). Although the association between the presence of abnormal symptoms and African-American race (OR: 2.04, 95%CI: 0.96, 4.35, p = 0.065) and average daily consumption of at least 2 caffeine drinks (OR: 2.08, 95%CI: 0.86, 5.02, p = 0.103) were not significant, there was a trend to reach the a priori significance level. Conclusions: This study identified several clinical parameters that are associated with symptoms suggestive of abnormal cardiac conditions. Larger studies need to be done to better sort out the clinical history that may contribute to false positives to further reduce false positives at heart screenings.

Exercise Recommendations for the Athlete With Coronary Artery Disease.

PURPOSE OF THE REVIEW: We provide a framework for formulating exercise prescriptions for those with CAD in order to achieve the "optimal" dose of exercise for each individual. RECENT FINDINGS: Multiple epidemiological studies demonstrate that exercise is inversely associated with atherosclerotic coronary artery disease (CAD), yet the risk of an acute coronary event is transiently elevated during vigorous exercise. In turn, CAD is the most common cause of exercise-related sudden cardiac death (SCD) in older athletes. When prescribing exercise recommendations for athletes with CAD, we should maintain equipoise between the benefits derived from sports participation and the risk of an adverse cardiac event. Athletes are not immune from atherosclerotic CAD, and we should perform risk assessments regardless of physical and athletic prowess. Cardiopulmonary exercise testing may be a useful tool to develop individualized exercise regimens for athletes with CAD.

International Recommendations for Electrocardiographic Interpretation in Athletes.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On February 26-27, 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.