View More View Less
  • 1 University of Nyíregyháza, Hungary
  • 2 Flór Ferenc Hospital of Pest County, Hungary
  • 3 KRKA Hungary Ltd., Hungary
  • 4 University of Physical Education, Hungary
  • 5 St. Imre University Teaching Hospital, Hungary
  • 6 Semmelweis University, Hungary
Restricted access

Purchase article

USD  $25.00

1 year subscription (Individual Only)

USD  $752.00

Background

Early repolarization in the anterior ECG leads (ERV2–4) is considered to be a sign of right ventricular (RV) remodeling, but its etiology and importance are unclear.

Methods

A total of 243 top-level endurance-trained athletes (ETA; 183 men and 60 women, weekly training hours: 15–20) and 120 leisure-time athletes (LTA; 71 men and 49 women, weekly training hours: 5–6) were investigated. The ERV2–4 sign was evaluated concerning type of sport, gender, transthoracic echocardiographic parameters, and ECG changes, which can indicate elevated RV systolic pressure [left atrium enlargement (LAE), right atrium enlargement (RAE), RV conduction defect (RVcd)].

Results

Stroke volume and left ventricular mass were higher in ETAs vs. LTAs in both genders (p < 0.01). Prevalence of the ERV2–4 sign was significantly higher in men than in women [p = 0.000, odds ratio (OR) = 36.4] and in ETAs than in LTAs (p = 0.000). The highest ERV2–4 prevalence appeared in the most highly trained triathlonists and canoe and kayak paddlers (OR = 13.8 and 5.2, respectively). Within the ETA group, the post-exercise LAE, RAE, and RVcd changes developed more frequently in cases with than without ERV2–4 (LAE: men: p < 0.05, females: p < 0.005; RAE: men: p < 0.05, females: p < 0.005; RVcd: N.S.). These post-exercise appearing LAE, RAE, and RVcd are associated with the ERV2–4 sign (OR = 4.0, 3.7, and 3.8, respectively).

Conclusions

According to these results, ERV2–4 develops mainly in male ETAs due to long-lasting and repeated endurance training. The ERV2–4 sign indicates RV’s adaptation to maintain higher compensatory pulmonary pressure and flow during exercise but its danger regarding malignant arrhythmias is unclear.

  • 1.

    Cappato R , Furlanello F , Giovinazzo V , Infusino T , Lupo P , Pittalis M , Foresti S , De Ambroggi G , Ali H , Bianco E , Riccamboni R , Butera G , Ricci C , Ranucci M , Pelliccia A , De Ambroggi L : J wave, QRS slurring, and ST elevation in athletes with cardiac arrest in the absence of heart disease. Marker of risk or innocent bystander? Circ. Arrhythm. Electrophysiol. 3, 305311 (2010)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Chandra N , Bastiaenen R , Papadakis M , Sharma S : Sudden cardiac death in young athletes. Practical challenges and diagnostic dilemmas. J. Am. Coll. Cardiol. 61, 10271040 (2013)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3.

    Corrado D , Basso C , Schiavon M , Thiene G : Screening for hypertrophic cardiomyopathy in young athletes. N. Eng. J. Med. 339, 364369 (1998)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Corrado D , Biffi A , Basso C , Pelliccia A , Thiene G : 12-lead ECG in the athlete: physiological versus pathological abnormalities. Br. J. Sports Med. 43, 669676 (2009)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Corrado D , Pelliccia A , Heidbuchel H , Sharma S , Link M , Basso C , Biffi A , Buja G , Delise P , Gussac I , Anastasakis A , Borjesson M , Bjørnstad HH , Carrè F , Deligiannis A , Dugmore D , Fagard R , Hoogsteen J , Mellwig KP , Panhuyzen-Goedkoop N , Solberg E , Vanhees L , Drezner J , Estes NA 3rd , Iliceto S , Maron BJ , Peidro R , Schwartz PJ , Stein R , Thiene G , Zeppilli P , McKenna WJ ; Section of Sports Cardiology, European Association of Cardiovascular Prevention and Rehabilitation: Recommendations for interpretation of 12-lead electrocardiogram in the athlete. Eur. Heart J. 31, 243259 (2010)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    D’Andrea A , Caso P , Scarafile R , Salerno G , De Corato G , Mita C , Di Salvo G , Allocca F , Colonna D , Caprile M , Ascione L , Cuomo S , Calabró R : Biventricular myocardial adaptation to different training protocols in competitive master athletes. Int. J. Cardiol. 115, 342349 (2007)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    D’Andrea A , Naeije R , D’Alto M , Argiento P , Golia E , Cocchia R , Riegler L , Scarafile R , Limongelli G , Di Salvo G , Citro R , Caso P , Russo MG , Calabrò R , Bossone E : Range in pulmonary artery systolic pressure among highly trained athletes. Chest 139, 788794 (2011)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    D’Andrea A , Riegler L , Golia E , Cocchia R , Scarafile R , Salerno G , Pezzullo E , Nunziata L , Citro R , Cuomos S , Caso P , Di Salvo G , Cittadini A , Russo MG , Calabró R , Bossom E : Range of right heart measurements in top-level athletes: the training impact. Int. J. Cardiol. 164, 4857 (2013)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9.

    Deschamps AM , Murphy E , Sun J : Estrogen receptor activation and cardioprotection in ischaemia reperfusion injury. Trends Cardiovasc. Med. 20, 7378 (2010)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Di Paolo FM , Schmied C , Zerguini YA , Junge A , Quattrini F , Culasso F , Dvorak J , Pelliccia A : The athlete’s heart in adolescent Africans: an electrocardiographic and echocardiographic study. J. Am. Coll. Cardiol. 59, 10291036 (2012)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11.

    Drezner JA , Ackerman MJ , Anderson J , Ashley E , Asplund CA , Baggish AL , Börjesson M , Cannon BC , Corrado D , DiFiori JP , Fischbach P , Froelicher V , Harmon KG , Heidbuchel H , Marek J , Owens DS , Paul S , Pelliccia A , Prutkin JM , Salerno JC , Schmied CM , Sharma S , Stein R , Vetter VL , Wilson MG : Electrocardiographic interpretation in athletes: the ‘Seattle Criteria’. Br. J. Sports Med. 47, 122124 (2013)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12.

    Drezner JA , Fischbach P , Froelicher V , Marek J , Pelliccia A , Prutkin JM , Schmied CM , Sharma S , Wilson MG , Ackerman MJ , Anderson J , Ashley E , Asplund CA , Baggish AL , Börjesson M , Cannon BC , Corrado D , DiFiori JP , Harmon KG , Heidbuchel H , Owens DS , Paul S , Salerno JC , Stein R , Vetter VL : Normal electrocardiographic findings: recognising physiological adaptations in athletes. Br. J. Sports Med. 47, 125136 (2013)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13.

    Engler RL , Smith P , LeWinter M , Gosink B , Johnson A : The electrocardiogram in asymmetric septal hypertrophy. Chest 75, 16773 (1979)

  • 14.

    Ferreira M , Santos-Silva PR , de Abreu LC , Valenti VE , Crispim V , Imaizumi C , Filho CF , Murad N , Meneghini A , Riera ARP , de Carvalho TD , Vanderlei LCM , Valenti EE , Cisternas JR , Filho OFM , Ferreira C : Sudden cardiac death athletes: systematic review. Sports Med. Arthrosc. Rehabil. Ther. Technol. 2, 1926 (2010)

    • Search Google Scholar
    • Export Citation
  • 15.

    Gussak I , Antzelevitch C : Early repolarization syndrome: clinical characteristics and possible cellular and ionic mechanisms. J. Electrocardiol. 33, 299309 (2000)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16.

    Gussak I , George S , Bojovic B , Vajdic B : ECG phenomena of the early ventricular repolarization in the 21 century. Indian Pacing Electrophysiol. J. 8, 149157 (2008)

    • Search Google Scholar
    • Export Citation
  • 17.

    Kawata H , Noda T , Yamada Y , Okamura H , Satomi K , Aiba T , Takaki H , Aihara N , Isobe M , Kamakura S , Shimizu W : Effect of sodium-channel blockade on early repolarization in inferior/lateral leads in patients with idiopathic ventricular fibrillation and Brugada syndrome. Heart Rhythm. 1, 7783 (2012)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18.

    La Gerche A , Burns AT , Mooney DJ , Inder WJ , Taylor AJ , Bogaert J , Maclsaac AI , Heidbüchel H , Prior DL : Exercise-induced right ventricular dysfunction and structural remodelling in endurance athletes. Eur. Heart J. 33, 9981006 (2012)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19.

    La Gerche A , Claessen G , Dymarkowski S , Voigt JU , De Buck F , Vanhees L , Droogne W , Van Cleemput J , Claus P , Heidbuchel H : Exercise-induced right ventricular dysfunction is associated with ventricular arrhythmias in endurance athletes. Eur. Heart J. 3, 19982010 (2015)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20.

    La Gerche A , Heidbüchel H , Burns AT , Mooney DJ , Taylor AJ , Pfluger HB , Inder WJ , MacIsaac AI , Prior DL : Disproportionate exercise load and remodeling of the athlete’s right ventricle. Med. Sci. Sport Exerc. 43, 974981 (2011)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21.

    Major Zs , Csajági E , Kneffel Zs , Kováts T , Szauder I , Sidó Z , Pavlik G : Comparison of left and right ventricular adaptation in endurance-trained male athletes. Acta Physiol. Hung. 102, 2333 (2015)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22.

    Major Zs , Kneffel Zs , Sidó Z , Komka Zs , Tóth M , Pavlik G : Repolarization changes in elite athletes (in Hungarian). Sportorvosi Szemle. 52, 1015 (2011)

    • Search Google Scholar
    • Export Citation
  • 23.

    Marijon E , Tafflet M , Celermajer DS , Dumas F , Perier MC , Mustafic H , Toussaint FF , Desnos M , Rieu M , Benameur N , Le Heuzey JY , Empana JP , Jouven X : Sports-related sudden death in the general population. Circulation 24, 672681 (2011)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24.

    Maron BJ , Doerer JJ , Haas TS , Tierney DM , Mueller FO : Sudden death in young competitive athletes. Analysis of 1866 death in the United States, 1980–2006. Circulation 119, 10851092 (2009)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25.

    Medvegy M , Antalóczy Z : Clinical significance of incomplete right bundle branch block (in Hungarian). Orv. Hetil. 134, 15251528 (1993)

    • Search Google Scholar
    • Export Citation
  • 26.

    Naeije R , Vanderpool R , Dhakal BP , Saggar R , Saggar R , Vachiery JL , Lewis GD : Exercise-induced pulmonary hypertension: physiological basis and methodological concerns. Am. J. Respir. Crit. Care Med. 187, 576583 (2013)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 27.

    Pavlik G , Olexó Z , Osváth P , Sidó Z , Frenkl R : Echocardiographic characteristics of male athletes of different age. Br. J. Sports Med. 35, 9599 (2001)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 28.

    Pedram A , Razandi R , Aitkenhead M , Levin ER : Estrogen inhibits cardiomyocyte hypertrophy in-vitro: antagonism of calcineurin-related hypertrophy through induction of MCIP1. J. Biol. Chem. 280, 2633926348 (2005)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29.

    Savard P , Cohen D , Lepeschkin E , Cuffin BN , Madias JE : Magnetic measurement of S-T and Q-T segment shifts in humans. Part I: early repolarization and left bundle branch block. Circ. Res. 53, 264273 (1983)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30.

    Sharma S , Merghani A , Mont L : Exercise and the heart: the good, the bad, and the ugly. Eur. Heart J. 36, 14451453 (2015)

  • 31.

    Sofi F , Capalbo A , Pucci N , Giuliattini J , Condino F , Alessandri F , Abbate R , Gensini GF , Califano S : Cardiovascular evaluation, including resting and exercise electrocardiography, before participation in competitive sports: cross sectional study. BMJ. 337, a346 (2008)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32.

    Teske AJ , Prakken NH , De Boeck BW , Velthuis BK , Martens EP , Doevendans PA , Cramer MJ : Echocardiographic tissue deformation imaging of right ventricular systolic function in endurance athletes. Eur. Heart J. 30, 969977 (2009)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33.

    Tikkanen JT , Junttila MJ , Anttonen O , Aro AL , Luttinen S , Kerola T , Sager SJ , Rissanen HA , Myerburg RJ , Reunanen A , Huikuri HV : Early repolarization: electrocardiographic phenotypes associated with favorable long-term outcome. Circulation 123, 26662673 (2011)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 34.

    Venteuolo CE , Klinger JR : Management of acute right ventricular failure in the intensive care unit. Ann. Am. Thorac. Soc. 11, 811822 (2014)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 35.

    Wilson MG , Sharma S , Carré F , Charron P , Richard P , O’Hanlon R , Prasad SK , Heidbuchel M , Brugada J , Salah O , Sheppard M , George KP , Whyte G , Hamilton B , Chalabi M : Significance of deep T-wave inversions in asymptomatic athletes with normal cardiovascular diagnostic conundrum. Br. J. Sports Med. 46, 5158 (2012)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36.

    Wu J , Stork TL , Perron AD , Brady WJ : The athlete’s electrocardiogram. Am. J. Emerg. Med. 24, 7786 (2006)

  • 37.

    Yan GX , Lankipalli RS , Burke JF , Musco S , Kowey PR : Ventricular repolarization components on the electrocardiogram. J. Am. Coll. Cardiol. 42, 401409 (2003)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38.

    Zaidi A , Sharma S : Arrhythmogenic right ventricular remodeling in endurance athletes: Pandora’s box or Achilles’ heel? Eur. Heart J. 36, 19551957 (2015)

    • Crossref
    • Search Google Scholar
    • Export Citation