Home /

Athletes and ECG

ECG interpretation in athletes

Athlete's Heart
Sudden Cardiac Death
Normal ECG in Athletes
Abnormal ECG in Athletes

Athlete's Heart

The heart of an athlete adapts and remodels to meet increased physical demands
The electrophysiological properties of the myocardium and the conduction system change
Action potential during depolarization

Creates higher voltage QRS complexes
QRS amplitude does not correlate with left ventricular hypertrophy

Right ventricular hypertrophy often results in incomplete right bundle branch block (RBBB)
There is an increased vagal tone (parasympathetic), which leads to:

Sinus bradycardia, sinus pauses
First-degree and second-degree AV block (Wenckebach)

Sudden Cardiac Death

Most common cause of sudden death in athletes during sports

Is sudden cardiac death

ECG serves as a screening examination for the heart's electrophysiology
The boundary between normal and abnormal ECG in athletes is questionable
An abnormal ECG finding indicates

further examinations focusing on the heart in athletes

Normal ECG in Athletes

The table shows ECG findings

that are considered a variant of normal in athletes

An asymptomatic athlete with these ECG findings

does not require further cardiac examinations

Normal ECG in athletes:

Sinus bradycardia ≤ 30/min.

Sinus respiratory arrhythmia

Ectopic atrial rhythm

Junctional rhythm

First-degree AV block

Second-degree AV block (Wenckebach)

Incomplete RBBB

Occurs in approximately 30-50% of athletes

Only voltage criteria for left ventricular hypertrophy

No other criteria: axis deviation, P mitrale...

Benign early repolarization

Convex ST elevations and negative T waves (V1-V4)

African/black athletes

Abnormal ECG in Athletes

The table shows ECG findings

that are considered abnormal ECG findings

Athletes with these ECG findings

require further cardiac examinations

Abnormal ECG in Athletes:
Negative T waves >1mm in at least 2 leads: (V2-V6, II, aVF, I, aVL)
ST depression (≥0.5mm in at least 2 leads)
Pathological Q waves >3mm, or >40ms in at least 2 leads (excluding III, aVR)
Complete LBBB
Prolonged ventricular conduction (QRS≥0.14s)
Left axis deviation
P mitrale
Right ventricular hypertrophy
Pre-excitation
Prolonged QT interval
Shortened QT interval
Brugada syndrome
Sinus bradycardia (<30/min.)
Sinus pause (≥3sec.)
Supraventricular tachycardia (excluding sinus tachycardia)
Ventricular extrasystole (≥2 VES in 10s, couplet, triplet)
Ventricular tachycardia

ECG in two healthy athletes, early repolarization, concave and convex ST segment elevation, negative T wave, positive T wave

Normal ECG in Athletes

These are ECG recordings from 2 healthy athletes
A: Benign early repolarization

Concave ST elevations and positive T waves

B: Benign early repolarization

Convex ST elevations and negative T waves

ECG healthy athletes, incomplete right bundle branch block (RBBB)

Normal ECG in an Athlete

This is a 25-year-old healthy athlete
Sinus rhythm
Incomplete right bundle branch block

ECG athlete, sport man, sinus bradycardia, early repolarisation, peaked T waves, voltage criteria for left ventricular hypertrophy

Normal ECG in an Athlete

This is a 29-year-old healthy athlete
Sinus bradycardia 43/min.

Calculation of frequency (1500/35 squares = 43)

Benign early repolarization

Voltage criteria for left ventricular hypertrophy (S-V1 + R-V5 >35mm)
Incomplete right bundle branch block
High T waves
This is a normal ECG finding in an athlete

ECG athlete hypertrophic cardiomyopathy, QRS voltage criteria for LVH, deep TWI and ST segment depression, left atrial and right atrial enlargement, left axis deviation

Abnormal ECG in an Athlete

Voltage criteria for left ventricular hypertrophy (S-V1 + R-V5 >35mm)
Deeply inverted T waves (I, aVL, V4-V6)
P pulmonale
Left axis deviation
This is an abnormal ECG finding in an athlete who had

hypertrophic cardiomyopathy

Normal ECG in an Athlete

Incomplete right bundle branch block

rSR (V1)
QRS < 120ms

This is a normal ECG finding in an athlete

ECG black athlete, elevation and convex ST segment elevation followed by T wave inversion in V1-V4, voltage left ventricular hypertrophy

Normal ECG in an Athlete

This is a 30-year-old African athlete
Voltage criteria for left ventricular hypertrophy (S-V1 + R-V5 >35mm)
ST elevations and negative T waves (V1-V4)
This is a normal finding in African athletes

Normal ECG in an Athlete

This is a 28-year-old athlete
Junctional rhythm (arrows)
This is a normal finding in athletes

ECG athlete, ectopic atrial rhythm, Negative P wave in inferior leads (II, III, aVF)

Normal ECG in an Athlete

This is a 38-year-old athlete
Ectopic atrial rhythm (arrows)

P waves are not from the SA node, as they are negative in the inferior leads (II, III, aVF)

This is a normal finding in athletes

Abnormal ECG athlete complete right bundle branch block, left axis deviation, right atrial enlargement - P pulmonale

Abnormal ECG in an Athlete

This is a 22-year-old athlete
Right bundle branch block
Left axis deviation
P pulmonale
This is an abnormal ECG finding

The athlete must undergo further heart-focused examinations

Abnormal ECG athlete deep pathological Q wave in V4-V6, I, aVL, hypertrophic cardiomyopathy

Abnormal ECG in an Athlete

This is an 18-year-old athlete
Pathological Q wave (V5-V6, I, aVL)
This is an abnormal ECG finding in an athlete who had

hypertrophic cardiomyopathy

Abnormal ECG athlete left bundle branch block (LBBB)

Abnormal ECG in an Athlete

This is a 26-year-old athlete
Left bundle branch block

Is always considered an abnormal ECG finding in athletes

This is an abnormal ECG finding

The athlete must undergo further heart-focused examinations

Abnormal ECG athlete, multiple premature ventricular complexes, PVC LBBB pattern

Abnormal ECG in an Athlete

This is a 29-year-old athlete
Ventricular extrasystoles (≥2 VES per 10s)
This is an abnormal ECG finding

The athlete must undergo further heart-focused examinations

Sources

ECG from Basics to Essentials Step by Step
litfl.com
ecgwaves.com
metealpaslan.com
medmastery.com
uptodate.com
ecgpedia.org
wikipedia.org
Strong Medicine
Understanding Pacemakers

Home /

Athletes and ECG

ECG interpretation in athletes

Athlete's Heart
Sudden Cardiac Death
Normal ECG in Athletes
Abnormal ECG in Athletes

Athlete's Heart

The heart of an athlete adapts and remodels to meet increased physical demands
The electrophysiological properties of the myocardium and the conduction system change
Action potential during depolarization

Creates higher voltage QRS complexes
QRS amplitude does not correlate with left ventricular hypertrophy

Right ventricular hypertrophy often results in incomplete right bundle branch block (RBBB)
There is an increased vagal tone (parasympathetic), which leads to:

Sinus bradycardia, sinus pauses
First-degree and second-degree AV block (Wenckebach)

Sudden Cardiac Death

Most common cause of sudden death in athletes during sports

Is sudden cardiac death

ECG serves as a screening examination for the heart's electrophysiology
The boundary between normal and abnormal ECG in athletes is questionable
An abnormal ECG finding indicates

further examinations focusing on the heart in athletes

Normal ECG in Athletes

The table shows ECG findings

that are considered a variant of normal in athletes

An asymptomatic athlete with these ECG findings

does not require further cardiac examinations

Normal ECG in athletes:

Sinus bradycardia ≤ 30/min.

Sinus respiratory arrhythmia

Ectopic atrial rhythm

Junctional rhythm

First-degree AV block

Second-degree AV block (Wenckebach)

Incomplete RBBB

Occurs in approximately 30-50% of athletes

Only voltage criteria for left ventricular hypertrophy

No other criteria: axis deviation, P mitrale...

Benign early repolarization

Convex ST elevations and negative T waves (V1-V4)

African/black athletes

Abnormal ECG in Athletes

The table shows ECG findings

that are considered abnormal ECG findings

Athletes with these ECG findings

require further cardiac examinations

Abnormal ECG in Athletes:
Negative T waves >1mm in at least 2 leads: (V2-V6, II, aVF, I, aVL)
ST depression (≥0.5mm in at least 2 leads)
Pathological Q waves >3mm, or >40ms in at least 2 leads (excluding III, aVR)
Complete LBBB
Prolonged ventricular conduction (QRS≥0.14s)
Left axis deviation
P mitrale
Right ventricular hypertrophy
Pre-excitation
Prolonged QT interval
Shortened QT interval
Brugada syndrome
Sinus bradycardia (<30/min.)
Sinus pause (≥3sec.)
Supraventricular tachycardia (excluding sinus tachycardia)
Ventricular extrasystole (≥2 VES in 10s, couplet, triplet)
Ventricular tachycardia

Normal ECG in Athletes

These are ECG recordings from 2 healthy athletes
A: Benign early repolarization

Concave ST elevations and positive T waves

B: Benign early repolarization

Convex ST elevations and negative T waves

Normal ECG in an Athlete

This is a 25-year-old healthy athlete
Sinus rhythm
Incomplete right bundle branch block

Normal ECG in an Athlete

This is a 29-year-old healthy athlete
Sinus bradycardia 43/min.

Calculation of frequency (1500/35 squares = 43)

Benign early repolarization

Voltage criteria for left ventricular hypertrophy (S-V1 + R-V5 >35mm)
Incomplete right bundle branch block
High T waves
This is a normal ECG finding in an athlete

Abnormal ECG in an Athlete

Voltage criteria for left ventricular hypertrophy (S-V1 + R-V5 >35mm)
Deeply inverted T waves (I, aVL, V4-V6)
P pulmonale
Left axis deviation
This is an abnormal ECG finding in an athlete who had

hypertrophic cardiomyopathy

Normal ECG in an Athlete

Incomplete right bundle branch block

rSR (V1)
QRS < 120ms

This is a normal ECG finding in an athlete

Normal ECG in an Athlete

This is a 30-year-old African athlete
Voltage criteria for left ventricular hypertrophy (S-V1 + R-V5 >35mm)
ST elevations and negative T waves (V1-V4)
This is a normal finding in African athletes

Normal ECG in an Athlete

This is a 28-year-old athlete
Junctional rhythm (arrows)
This is a normal finding in athletes

Normal ECG in an Athlete

This is a 38-year-old athlete
Ectopic atrial rhythm (arrows)

P waves are not from the SA node, as they are negative in the inferior leads (II, III, aVF)

This is a normal finding in athletes

Abnormal ECG in an Athlete

This is a 22-year-old athlete
Right bundle branch block
Left axis deviation
P pulmonale
This is an abnormal ECG finding

The athlete must undergo further heart-focused examinations

Abnormal ECG in an Athlete

This is an 18-year-old athlete
Pathological Q wave (V5-V6, I, aVL)
This is an abnormal ECG finding in an athlete who had

hypertrophic cardiomyopathy

Abnormal ECG in an Athlete

This is a 26-year-old athlete
Left bundle branch block

Is always considered an abnormal ECG finding in athletes

This is an abnormal ECG finding

The athlete must undergo further heart-focused examinations

Abnormal ECG in an Athlete

This is a 29-year-old athlete
Ventricular extrasystoles (≥2 VES per 10s)
This is an abnormal ECG finding

The athlete must undergo further heart-focused examinations

Sources

ECG from Basics to Essentials Step by Step
litfl.com
ecgwaves.com
metealpaslan.com
medmastery.com
uptodate.com
ecgpedia.org
wikipedia.org
Strong Medicine
Understanding Pacemakers