Most data assessing the accuracy of electrocardiographic (ECG) screening in identifying cardiac pathology in athletes are derived from relatively unselected cohorts of subjects involved in competitive sports. We hypothesized that the prevalence of ECG abnormalities may be greater in athletes performing the greatest combination of exercise intensity and duration, namely professional endurance athletes. A total of 1,007 male and 254 female elite adult athletes underwent cardiovascular screening inclusive of an electrocardiogram, interpreted using the 2010 European Society of Cardiology guidelines. Training-related ECG changes (group 1) were more common in endurance athletes (EAs) than nonendurance athletes (NEAs; 90.8% vs 86.0%, p = 0.04), as were multiple (=2) training-related changes (78.9% vs 53.5%, p <0.0001). Group 2 ECG changes (previously considered uncommon and training unrelated) were seen in 18.1% of subjects and were twice as prevalent in EAs compared with NEAs (29.9% vs 15.1%, p <0.0001). Right ventricular hypertrophy (4.4% EAs vs 1.5% NEAs, p <0.005) and deep right precordial T-wave inversion (14.3% EAs vs 4.7% NEAs, p <0.0001) were 3 times as common in EAs. Both group 1 and group 2 changes were similarly prevalent among elite male and female athletes and were more common in EAs regardless of gender. In conclusion, ECG abnormalities are very common in elite athletes and are more common in EAs than NEAs. Right ventricular hypertrophy and deep right precordial T-wave inversion are particularly common in EAs, possibly because of increased structural and/or electrical right ventricular remodeling in this subgroup. The predictive value of ECG screening and criteria for abnormal findings in elite EAs requires specific appraisal. Current European Society of Cardiology (ESC) athlete electrocardiographic (ECG) interpretation guidelines classify ECG changes as either those which are common in athletes and thought to be training related (group 1) or those thought to be uncommon, training unrelated, and which warrant further investigation to exclude cardiac pathology (group 2).1 These guidelines are derived from studies of unselected cohorts of young subjects involved in competitive sports without a defined threshold for the quantity or quality of athletic conditioning. In fact, most studies assessing the prevalence of abnormal ECG patterns have predominantly comprised male subelite nonendurance athletes (NEAs).2, 3, 4 and 5 Thus, all "athletes" are considered equal in regard to ECG criteria, although there are abundant data demonstrating that cardiac remodeling ("athlete's heart") is determined by the volume and intensity of exercise exposure, with pure endurance-trained athletes demonstrating larger cardiac dimensions than NEAs, and those competing at the highest level showing the most marked adaptations.6, 7 and 8 Therefore, we hypothesized that ECG changes, especially group 2 changes, would be more common in those performing the greatest combination of exercise intensity and duration, namely professional endurance athletes (EAs). Furthermore, we sought to test whether this hypothesis also applied to elite female athletes given that experience is even more limited for this group.
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