Background Sudden cardiac death (SCD) is a rare but tragic event that may be triggered by intense exercise. Pre-participation screening with a 12-lead ECG is recommended by many elite sporting organisations as a means of identifying athletes at greater risk of SCD. Methods Cardiac evaluation, including a 12-lead ECG, was performed periodically on athletes affiliated with High Performance Sport New Zealand from January 2012- May 2022 who were competing in sports with the highest combination of intensity and endurance (categorized as IIIc sports in the ACC classification). The ECG was analyzed according to the International Criteria to determine 1) whether the ECG was abnormal and 2) whether this led to a cardiac diagnosis. Male (M) and female (F) differences in abnormal findings were compared using two-tailed Chi squared tests with p<0.05 considered significant. Results There were 768 ECGs analysed from 345 athletes (rowing n=199, cycling n=83, canoeing n=37, other IIIc sports n=26; 44% female). The rate of LVH by voltage criteria was 29% (F: 18%, M: 39%, p<0.0001), partial RBBB was 24% (F: 23%, M: 24%, p=0.59), abnormal T wave inversion (TWI) was 2.1% (F: 3.4%, M: 1.0%, p=0.02). Overall, 3.1% of ECGs were abnormal. Further work-up led to a cardiac diagnosis in 6 athletes (1.7% of athletes). The most common cardiac diagnosis uncovered was Wolff-Parkinson-White (WPW) syndrome, which was found in 0.9% of this IIIc athlete population, a rate 3 times higher than the general population. There were no cardiac arrests or deaths in 1973 years of athlete follow-up. Conclusion WPW syndrome was a relatively common diagnosis for athletes in IIIc sports. Abnormal TWI was significantly more common in female athletes, which raises the issue of whether TWI in lead V3 should be considered normal in a female endurance athlete. LVH by voltage criteria was significantly more common in male endurance athletes. There was a relatively low prevalence of ECG abnormalities, likely due to the greater specificity of contemporary ECG guidelines given that common ECG findings like LVH and partial RBBB are now considered normal for athletes.
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