Cardiology in Sport Flashcards by Léa Adamson

Group 1 training related changes

isolated voltage criteria for LVH (often normal size on echo)
early repolarisation
incomplete RBBB
First degree AV block
Sinus bradycardia

How well did you know this?

Not at all

Perfectly

Which ECG leads represent the left ventricle?

leads v5 and v6

How well did you know this?

Not at all

Perfectly

What is the general appearance of ECG waveforms in LVH?

Tall R in V5/6

Deep S in V1/2

How well did you know this?

Not at all

Perfectly

What is the voltage criteria for LVH?

Sokolow-Lyon criteria:

S in V1/2
PLUS
R in V5/6 ≥35 mm (7 large squares)

total height of R waves is >5 large squares in V5/6

How well did you know this?

Not at all

Perfectly

2 episodes of dizziness post-exercise in a competitive athlete- what does the ECG show and is it pathological?

saddle shaped ST elevation leads 2,1 V3-6
voltage criteria for LVH

This is normal- early repolarisation is normal in athletes

How well did you know this?

Not at all

Perfectly

What does this ECG show and what does it mean in a young athlete?

biphasic T-wave inversion in lead 3

This is pathological even in an athlete and is not a sign of athletic adaptation

How well did you know this?

Not at all

Perfectly

Black athlete, aSx

prolonged PR interval (first degree heart block)
voltage criteria for LVH (>5 squares in V5/6)
early repolarisation in V2/3
J point elevation
T wave inversion V1-3

%black athletes with T wave inversion is quite high, especially in V1-4. So this is normal. If the T wave inversion was WIDESPREAD you’d be more suspicious of an inherited cardiomyopathy

How well did you know this?

Not at all

Perfectly

Which ethnicity shows high rates of t-wave inversion?

Black athletes: Middle-west Africa and lesser extent Afro-caribbean

TWI in V1-4 present in 12-13% black athletes, usually preceded by ST elevation

How well did you know this?

Not at all

Perfectly

When is TWI in black athletes abnormal?

widespread
TWI in inferior or lateral leads

Suggests cardiomyopathy eg hypertrophic cardiomyopathy

How well did you know this?

Not at all

Perfectly

What does this ECG show and is it normal or abnormal?

R wave progression in lead 3
ST depression in lateral leads- this is ALWAYS PATHOLOGICAL
Widespread TWI

How well did you know this?

Not at all

Perfectly

What is a pathogical Q wave?

associated with hypertrophic cardiomyopathy
ratio of Q wave to R wave- should be <1/4 of R wave
>0.4mV deep in any lead except 3 and aVR

How well did you know this?

Not at all

Perfectly

15 y/o underwent pre-participation screening- what are the obvious abnormalities

Very wide neck to T wave- unusual wave morphology

- QTc (QT interval corrected to HR) is prolonged

How well did you know this?

Not at all

Perfectly

How is QT interval measured

Absolute QT interval is measured from the beginning of Q to end of T
QT is corrected for HR using the Bazett formula = QTc

How well did you know this?

Not at all

Perfectly

Issue with Bazetts formula

not good at tach/brady cardias

How well did you know this?

Not at all

Perfectly

What is the criteria for QTc elongation in males and females

QTc> 440ms in males
QTc >460 in females

(each large square is 200ms 0.2s)
A lot of athletes have electrolyte imbalance, tired etc and goes below cut offs

How well did you know this?

Not at all

Perfectly

What factors affect QTc?

FHx
U waves
Subtle T-wave changes
HR
repolarisation abnormalities
electrolytes: low K+, low Mg2+, low/high Ca2+
Drugs
Diurnal variations

How well did you know this?

Not at all

Perfectly

problems with measuring QTc in athletes

Slow HR
Sinus arrhythmia
Slightly wide QRS complexes
T-U complexes

How well did you know this?

Not at all

Perfectly

What is a common ECG finding in athletes that can lead to a falsely elongated QTc?

U waves are common in athletes

They precede T-waves and increase the measurement of the QTc

How to correctly measure QT interval

If you have any doubts from automatic reading you need to do this:

1) Use limb lead that best shows T wave- lead 5 or 2 usually
2) Beginning of QRS complex to end of T wave (work out like diagram)
3) average of 3-5 beats
4) Adjust for HR (measure during peak plasma conc if using QT prolonging medication)

What does this exercise stress test show? What are the chances of this being pathological

paradoxical prolongation of QTc- roughly >1/2 way between next R wave
increases 4 minutes into recovery

QTC>490 is basically diagnostic of long QT syndrome

What scoring system is used to determine the probability of long QT

Schwartz-score
- <1 = low
- 1.5-3 = intermediate
- >3.5 = high
difficult in athletes as lots have syncope, long QTC and resting bradycardia so often can be moderate but healthy

What was the issue with using the Schwartz-score in athletes? What alternative was devised?

up to 40% false positive in black athletes

Seattle criteria was then used as screening for athletes

What dos the following ECG show?

LAD

Lead 1 is up and 3 is down

What does the following ECG show?

Left axial enlargement

negative p wave in lead 1

Sign of left axial enlargement

negative p wave in V1

sign of right axial enlargement

Tall p waves in lead 2

Criteria for RVH

Sum of R in V1 + S in V5/6 >10mm opposite of LVH

When screening athletes for pathology, what steps are taken to eliminate false positives?

1) European Society of Cardiology guidelines, adjust for training related normal variants: - sinus bradycardia - first deg. AV block - Incomplete RBBB - Early repolarisation - Isolated QRS voltage criteria for LVH 2) Refined Seattle criteria if not present in isolation - left/right atrial enlargement - LAD/RAD - RVH - TWI widespread 3) If 2 or more of refined criteria present: - ST depression - Path Q waves - TWI beyond V4 - arrhythmia

aSx 15yr old athlete. What does this ECG show?

- LVH criteria - T wave inversion in V1 and V2 This is common in <14yr old athletes but past 16 is mostly pathological

Causes of sudden cardiac death

most commonly cardiomyopathy congenital and anatomical abnormalities electrical disorders Vast majority in young athletes <17yrs (sceening could have been easy)

Mobitz type 1 | Slightly elongated QTc

What does this ECG of a 16yr old white athlete show? what do these findings suggest?

- short PR interval (this can be normal in athletes) - TWI extending to V3 (pathological) - Poor R wave progression (from V1-6 R waves should increase and S decrease)- suggests underlying cardiomyopathic condition

State the criteria for further Ix for anterior TWI

Abnormal if TWI beyond: - V1 in white - V4 in black

What other ECG sign can we look at to help us decide whether the TWI is pathological or non-pathological?

ST segment morphology A = normal athlete shows J point elevation- this is REASSURING E = ST depression is mostly always pathological

What are the abnormalities in the following ECG an what do these suggest?

- peaked p waves - TWI in V2/3 - Shallow T wave morphology + Q wave - prolonged QTc - prolonged PR suggests hypokalaemia

Early changes in hypokalaemia

- flattening or T wave inversion - prominent U waves - ST segment depression - prolonged QT interval

Late changes hypokalaemia

- prolonged PR interval - decreased QRS voltage - widened QRS - ventricular arrhythmia

What does the following ECG show?

secondary heart block- Mobitz type 1 | Normal in athletes as they are often sinus brady

Why are athletes more likely to exhibit sinus bradycardia?

- increased vagal tone - reduces intrinsic sinus SAN rate - reverses on detraining

Are heart blocks common in athletes?

- Junctional rhythm and 1st degree heart block common (PR>200ms) - Second degree (Mobitz type 1) in 10% athletes Mobitz type 2 and third degree are rare and warrant further investigation

which ECG findings warrant further investigations?

- TWI - ST depression - Pathological Q waves - Complete LBBB - Ventricular pre-excitation (delta waves) - Long QT - >2PVCs per 10s - Tachyrrhythmias

Normal ECG findings in athletes

- sinus brady - 1st degree AV block - Mobitz type 1 2nd deg AV block - Voltage criteria for LVH/RVH - Incomplete RBBB - Early repolarisation - TWI V1-4 in black athletes

Borderline ECG findings in athletes

- Left or right atrial enlargement - LAD/RAD - Complete RBBB if there are 2+, FHx or Sx, further evaluation

Summary of Ix for different ECG findings in athletes