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

Remembering the Occam’s Razor: Could simple electrocardiographic findings provide relevant predictions for current hemodynamic criteria of pulmonary hypertension?

Background: We evaluated the predictive value of electrocardiographic (ECG) findings for pulmonary hemodynamics assessed by right heart catheterization (RHC). Methods: Our study population comprised 562 retrospectively evaluated patients who underwent RHC between 2006 and 2022. Correlations between ECG measures and pulmonary arterial systolic and mean pressures (PASP and PAMP) and pulmonary vascular resistance (PVR) were investigated. Moreover, receiver operating characteristic (ROC) curve analysis assessed the predictive value of ECG for pulmonary hypertension (PH) and precapillary PH. Results: The P-wave amplitude (Pwa) and R/S ratio (r) in V1 and V2, Ra in augmented voltage right (aVR), right or indeterminate axis, but not P wave duration (Pwd) or right bundle branch block (RBBB) significantly correlated with PASP, PAMP, and PVR (P 0.16 mV, Ra in aVR > 0.05 mV, QRS axis > 100° and R/Sr in V1 > 0.9 showed the highest area under curve (AUC) values for PAMP > 20 mm Hg. Using the same cutoff value, Ra in aVR, Pwa, QRS axis, and R/Sr in V1 showed highest predictions for PVR > 2 Wood Units (WU). Conclusion: In this study, Pwa, Ra in aVR, right or indeterminate axis deviations, and R/Sr in V1 and V2 showed statistically significant correlations with pulmonary hemodynamics, and Ra in aVR, R/Sr in V2 and V1, QRS axis, and Pwa contributed to variance for PASP, PAMP, and PVR, respectively. Moreover, Pwa, Ra in aVR, QRS axis, and R/Sr in V1 seem to provide relevant predictions for PH and precapillary PH

The Impact of Ethnicity on Cardiac Adaptation.

Regular intensive exercise is associated with a plethora of electrical, structural and functional adaptations within the heart to promote a prolonged and sustained increase in cardiac output. Bradycardia, increased cardiac dimensions, enhanced ventricular filling, augmentation of stroke volume and high peak oxygen consumption are recognised features of the athlete's heart. The type and magnitude of these adaptations to physical exercise are governed by age, sex, ethnicity, sporting discipline and intensity of sport. Some athletes, particularly those of African or Afro-Caribbean (black) origin reveal changes that overlap with diseases implicated in sudden cardiac death. In such instances, erroneous interpretation has potentially serious consequences ranging from unfair disqualification to false reassurance. This article focuses on ethnic variation in the physiological cardiac adaption to exercise

Exercise stress testing in clinical practice

Exercise stress testing is an important diagnostic tool for evaluating patient’s cardiovascular performance. The present review describes the accuracy and the value of exercise stress testing in different settings: after an acute coronary event, after percutaneous coronary intervention or coronary artery bypass graft; in patients risk assessment before non-cardiac surgery; in diabetic population; in patients with baseline electrocardiographic abnormalities. Moreover, this review provides insights relating to test accuracy in women and geriatric patients. Finally, this review explores new variables/parameters (dyspnea, chronotropic incompentence, heart rate recovery, functional capacity, integrated scores) that in the last few years added an incremental value to conventional analysis of exercise-induced angina or electrocardiographic changes

Comparing Non-invasive Inverse Electrocardiography With Invasive Endocardial and Epicardial Electroanatomical Mapping During Sinus Rhythm

This study presents a novel non-invasive equivalent dipole layer (EDL) based inverse electrocardiography (iECG) technique which estimates both endocardial and epicardial ventricular activation sequences. We aimed to quantitatively compare our iECG approach with invasive electro-anatomical mapping (EAM) during sinus rhythm with the objective of enabling functional substrate imaging and sudden cardiac death risk stratification in patients with cardiomyopathy. Thirteen patients (77% males, 48 ± 20 years old) referred for endocardial and epicardial EAM underwent 67-electrode body surface potential mapping and CT imaging. The EDL-based iECG approach was improved by mimicking the effects of the His-Purkinje system on ventricular activation. EAM local activation timing (LAT) maps were compared with iECG-LAT maps using absolute differences and Pearson’s correlation coefficient, reported as mean ± standard deviation [95% confidence interval]. The correlation coefficient between iECG-LAT maps and EAM was 0.54 ± 0.19 [0.49–0.59] for epicardial activation, 0.50 ± 0.27 [0.41–0.58] for right ventricular endocardial activation and 0.44 ± 0.29 [0.32–0.56] for left ventricular endocardial activation. The absolute difference in timing between iECG maps and EAM was 17.4 ± 7.2 ms for epicardial maps, 19.5 ± 7.7 ms for right ventricular endocardial maps, 27.9 ± 8.7 ms for left ventricular endocardial maps. The absolute distance between right ventricular endocardial breakthrough sites was 30 ± 16 mm and 31 ± 17 mm for the left ventricle. The absolute distance for latest epicardial activation was median 12.8 [IQR: 2.9–29.3] mm. This first in-human quantitative comparison of iECG and invasive LAT-maps on both the endocardial and epicardial surface during sinus rhythm showed improved agreement, although with considerable absolute difference and moderate correlation coefficient. Non-invasive iECG requires further refinements to facilitate clinical implementation and risk stratification

Zastosowanie elektrokardiografii w ostrych i przewlekłych chorobach z zajęciem prawej komory serca

Electrocardiography is a basic diagnostic tool and one that plays a significant role in differentiating many diseases, including those involving the right heart. The diagnosis of right ventricular (RV) pathology is difficult due to the complex structure and the wide spectrum of haemodynamic disorders resulting from its dysfunction. The use of a standard electrocardiogram (ECG) with right-sided leads can be a valuable complement of imaging tests, especially when these are not quickly available. Numerous electrocardiographic abnormalities are observed in the course of acute pulmonary embolism, chronic pulmonary hypertension, right ventricular myocardial infarction, or arrhythmogenic right ventricular cardiomyopathy, and some of these also have prognostic significance. Unfortunately, despite its simplicity and utility, ECG is insufficiently sensitive and specific to be the single tool in the recognition of RV pathologies. ECG is a common, inexpensive, non-invasive and easily accomplished complementary test, which can be useful in diagnostic algorithm of right heart diseases.Elektrokardiografia (EKG) odgrywa znaczącą rolę w różnicowaniu wielu chorób, w tym przebiegających z zajęciem prawego serca. Rozpoznanie patologii prawej komory (RV) bywa trudne ze względu na złożoną budowę oraz szerokie spektrum zaburzeń hemodynamicznych wynikających z jej dysfunkcji. Standardowy zapis EKG czynności serca uzupełniony o rejestrację odprowadzeń prawokomorowych może być w tym przypadku cennym uzupełnieniem badań obrazowych, zwłaszcza gdy te nie są szybko dostępne. W przebiegu ostrej zatorowości płucnej, nadciśnienia płucnego, zawału prawej komory czy arytmogennej kardiomopatii prawokomorowej obserwuje się liczne nieprawidłowości elektrokardiograficzne pomocne w diagnostyce, a część z nich ma znaczenie prognostyczne. Niestety, mimo swojej prostoty i użyteczności EKG cechuje się niedostateczną czułością i swoistością, by mógł stanowić pojedyncze narzędzie diagnostyczne w wykrywaniu nieprawidłowości RV. Elektrokardiografia to powszechne, tanie, nieinwazyjne i łatwe do wykonania badanie uzupełniające, które może mieć istotne znaczenie w algorytmie diagnostycznym różnych chorób przebiegających z zajęciem RV

Old Dog, New Tricks - Usefulness of the ECG in Monitoring Acute Rejection Post Cardiac Transplantation

Electrocardiographic abnormalities have been described in the setting of acute rejection following orthotopic cardiac transplantation. The following is a brief commentary related to an interesting case report by Goldraich et al. which was recently published in the VAD Journal

Innovations and mechanisms in pacing therapy for heart failure

Despite pharmacological advances, heart failure remains a major cause of mortality and morbidity. Pacing therapy for heart failure was achieved in the 1990s with the advent of biventricular pacing (BVP). BVP shortens ventricular activation time and has thus been referred to as ‘cardiac resynchronization therapy’ (CRT). However BVP has other effects including shortening of atrioventricular delay: the contributions of its effects to its overall benefit have yet to be elucidated. Ventricular activation is not normalised by BVP, indicating scope for more effective resynchronization. This thesis explores mechanisms and innovations in pacing therapy for heart failure through measurement of haemodynamic and electrical parameters with high precision and resolution during BVP, right ventricular pacing (RVP) and His bundle pacing (HBP), where the His-Purkinje conduction system is directly stimulated. HBP offers both an innovation in pacing and a model to study conventional pacing. HBP can deliver physiological CRT by overcoming left bundle branch block (LBBB) to normalise QRS appearances but its performance relative to BVP is not known. When performed proximally, or using lower energy, HBP can preserve intrinsic LBBB. In Chapter 3, the electro-mechanical effects of conventional BVP are compared with LBBB correction by HBP. Chapter 4 uses non-invasive electrical mapping to identify mechanisms and predictors of LBBB correction by HBP, comparing it with narrow QRS. Capture of the His bundle can be alone (selective HBP) or alongside myocardial capture (non-selective): the effect of this on HBP is studied in Chapter 5. In Chapter 6, the haemodynamic effects of proximal/low-energy HBP, where LBBB is preserved but atrioventricular timing can be optimised, is compared to BVP and RVP to measure the contribution of atrioventricular delay shortening to the overall benefit of BVP. By evaluating innovative therapies and improving our understanding of existing therapies, hopefully this thesis will advance pacing therapy for heart failure.Open Acces