Significance of Ventricular Tachyarrhythmias in Trained Athletes
October 1, 2002 3 minutes read
Abstract & Commentary
Synopsis: Even frequent and complex ventricular arrhythmias may be seen in competitive athletes and, in the absence of structural heart disease, they have a benign prognosis.
Source: Biffi A, et al. J Am Coll Cardiol. 2002;40: 446-452.
In this report, biffi and colleagues from the Italian Institute of Sport Science describes the prognostic significance of premature ventricular depolarizations (PVDs) in trained athletes. In Italy, all athletes undergo cardiovascular screening with a history, physical exam, and an electrocardiogram (ECG). Out of 15,889 athletes in their data bank, 355 who had > 3 PVDs on their resting 12-lead ECG or who complained of palpitations underwent 24-hour ambulatory ECG monitoring, symptom limited exercise testing, and 2-dimensional echocardiography. Selected patients who had particularly frequent or complex PVDs underwent additional studies including magnetic resonance imaging (MRI), nuclear imaging, endomyocardial biopsy, and electrophysiologic study.
Among the 355 patients in this report, 273 (77%) were male and the mean age was 24 years. They were divided into 3 groups. Group A subjects (n = 71) had > 2000 PVDs and > 1 nonsustained ventricular tachycardia episodes (NSVT) during the 24-hour ECG. Group B (n = 153) and group C (n = 131) subjects had > 100 to < 2000 PVDs and < 100 PVDs in 24 hours, respectively. All subjects had competed on a national or international level in a variety of sports.
Of the 355 athletes, 329 showed no evidence of structural cardiac disease. The remaining 26 were found to have either mitral valve prolapse with mild-to-moderate mitral regurgitation (n = 11), arrhythmogenic right ventricular cardiomyopathy (n = 7), myocarditis (n = 4), and dilated cardiomyopathy (n = 4). Except for 5 subjects with mitral valve prolapse in group B, all other athletes with identified structural abnormalities were in group A. Approximately two thirds of the athletes had PVDs with left bundle branch block morphology, often with an inferior axis consistent with a right ventricular outflow tract site of origin. PVDs disappeared with exercise in 65% of group A subjects, 72% of group B subjects, and 93% of group C subjects. Electrophysiologic studies were performed in 24 subjects but inducible sustained ventricular tachycardia was seen in only one. Athletes in group A were excluded from competition for a minimum of 3 months. One of these individuals died suddenly during a competitive field hockey game. He was playing against medical advice at the time. There were no other deaths in any group over 8.4 ± 6.3 years. Drug therapy was used in only 8 subjects, all with identified cardiovascular disease.
Biffi et al conclude that even frequent and complex ventricular arrhythmias may be seen in competitive athletes and, in the absence of structural heart disease, they have a benign prognosis.
Comment by John P. DiMarco, MD, PhD
Italy has a nationwide screening program for competitive athletes that provides a unique database for studies such as the one reported here. It has long been known that ECG abnormalities including increased R- or S- wave voltages, ST segment and T wave abnormalities, deep Q waves, and frequent or complex PVDs are more common in competitive athletes than in the general population. The rare tragic episodes of sudden death in athletes, however, attract considerable attention and cardiologists are often asked to "clear" individuals to participate in sports.
Although the data in this paper are, in many ways reassuring, it is difficult to translate these findings into routine practice. All of these athletes were competitors on a national and international level and they had survived years of training and competition to get to that level. Extrapolation of these data to younger, less proficient athletes more likely to present to a cardiologist cannot be justified.
Recently, NASPE published the results of a consensus conference on arrhythmias in athletes (Estes N, et al. J Cardiovasc Electrophysiol. 2001;12:1208-1217). These documents provide careful guidelines that clinicians should follow when asked to evaluate athletes. Those with identifiable structural abnormalities including hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, coronary artery anomalies or disease, dilated cardiomyopathy, and long QT syndromes should be restricted from competitive sports. Symptomatic individuals without structural heart disease may participate after a successful radiofrequency ablation.
Dr. DiMarco is Professor of Medicine, Division of Cardiology University of Virginia, Charolettesville.
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