Author + information
- Received February 11, 2015
- Revision received March 16, 2015
- Accepted April 20, 2015
- Published online June 30, 2015.
- Abbas Zaidi, BSc (Hons), MBBS, MD∗,
- Nabeel Sheikh, BSc (Hons), MBBS∗,
- Jesse K. Jongman, MD†,
- Sabiha Gati, BSc (Hons), MBBS∗,
- Vasileios F. Panoulas, MD, PhD‡,
- Gerald Carr-White, BSc (Hons), MBBS, PhD§,
- Michael Papadakis, MBBS, MD∗,
- Rajan Sharma, BSc (Hons), MBBS, MD∗,
- Elijah R. Behr, MBBS, MD∗ and
- Sanjay Sharma, BSc (Hons), MBChB, MD∗∗ ()
- ∗St. George’s University of London, London, United Kingdom
- †Isala Clinics, Zwolle, the Netherlands
- ‡Imperial College Healthcare National Health Service Trust, London, United Kingdom
- §Guy’s and St. Thomas’s Hospital, London, United Kingdom
- ↵∗Reprint requests and correspondence:
Prof. Sanjay Sharma, Division of Cardiovascular Sciences, St. George’s University of London, Cranmer Terrace, SW17 0RE, London, United Kingdom.
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.
Drs. Zaidi, Sheikh, Gati, and Papadakis have received research grants from the charitable organization Cardiac Risk in the Young. Dr. Sharma has been a coapplicant on previous grants from Cardiac Risk in the Young to study athletes and nonathletes. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received February 11, 2015.
- Revision received March 16, 2015.
- Accepted April 20, 2015.
- American College of Cardiology Foundation