Cardiology in Sport

Question 1

Interpreting ECG

Answer 1

Start at rhythm strip (III)- is there a P wave, followed by a QRS
What is PR interval
Is it followed by normal QT interval and any ST changes
What is sinus rhythm
Number of big squares R wave has

Question 2

R wave and LVH

Answer 2

If more than 5 big squares, suggestive of LVH

OR if biggest S wave + biggest R wave bigger than 7 big squares

Question 3

R wave + athletes

Answer 3

R wave>5 big squares common in athletes

Rarely coincides with their acc being LVH at eco

Question 4

Isolated Sokolow-Lyon voltage criterion for LVH

Answer 4

Common in male athletes and does not warrant further investigation

Question 5

Early repolarisation pattern accompanied by concave ST segment elevation

Answer 5

Identified in 25-40% of highly trained athletes

More common in males, black athletes and those with sinus bradycardia

Question 6

T wave inversion in people with chest pain

Answer 6

Think MI

But can be other causes

Question 7

Bi-phasic T wave inversion in leads V3

Answer 7

Would be considered abnormal ECG and not due to exercise in white athlete

Question 8

Black athletes + T wave inversion

Answer 8

Higher in prevalence

Thought to be more physiological

Question 9

Many inverted T waves

Answer 9

Regardless of ethnicity, start thinking about myopathic process, and generally an inherited cardiac myopathy- one of most common is hypertrophic cardiomyopathy

Question 10

TWI in leads V1-4 present in what percentage of black athletes

Answer 10

12-13%

Usually preceded by J-point and convex ST segment elevation

Question 11

ESC criteria deem any TWI beyond … as abnormal

Answer 11

V1

Question 12

If preceding ST segment to TWI is …, suggestive of pathology

Answer 12

Depressed

Question 13

ST segment depression

Answer 13

Should always be considered pathological

Question 14

Pathological Q wave

Answer 14

Shouldn’t have this regardless of how much you exercise
Height + length make it pathological
Should be less than a quarter of the R wave

Question 15

Prevalence of Q waves in athletes

Answer 15

0.7% vs controls 1.2%

Question 16

Measurement pathological Q wave

Answer 16

> 0.4mV deep in any lead except III, aVR

Question 17

QT interval

Answer 17

Measured rom beginning of Q wave to end of T wave

Has to be corrected for HR using Bazett formula

Question 18

Bazzett Formula

Answer 18

QTc=QT/(square root of RR)

Question 19

When should QT interval be measured

Answer 19

During peak plasma concentration of a QT-prolonging medication

Question 20

QTc abnormal in males

Answer 20

> 440ms

Question 21

QTc abnormal in females

Answer 21

> 460ms

Question 22

QTc interval affected by

Answer 22

Diurnal variations
Drugs
Clinical history + familial evaluation
U waves
Subtle T wave changes
HR
Repolarization abnormalities
Decreased K+
Decreased Mg2+
Decreased Ca2+
Increased Ca2+

Question 23

Problems with measuring QT interval in athletes

Answer 23

Slow HR
Sinus arrhythmia
Slightly wide QRS complexes
T-U complexes

Question 24

U waves

Answer 24

Common in athletes
Always follow your T wave
Can interfere with measurement of T wave
Are <50% of the height of the preceding T wave

Question 25

Measuring QT

Answer 25

Summit of T wave to isometric line across that angle

Question 26

Probability of long QT syndrome factors that give points on ECG

Answer 26

``` QTC>480- 3 points QTC 460-479- 2 points QTC 450-9 (males)- 1 point QTC >480ms at 4th min of recovery from ETT- 1 point Torsades de pointes- 2 T wave alternans- 1 >3 leads notched T waves-1 Bradycardia for age- 0.5 Syncope with stress-2 Syncope without stress-1 Congenital deafness- 0.5 Family history with definite LQTS- 1 Unexplained sudden death in 1st degree fam member <30 ```

Question 27

Probability of long QT criterion- <1 point

Answer 27

Low probability

Question 28

Probability of long QT criterion- 1.5-3 points

Answer 28

Intermediate probability

Question 29

Probability of long QT criterion- >3.5 points

Answer 29

High probability

Question 30

Problems with ESC 2010 criteria for QTC

Answer 30

17-32% false positives in white athletes | 30-40% false positives in black athletes

Question 31

Problems with Seattle criteria 2013 WTC

Answer 31

4-9% white athletes false positive | 16% black athletes false positive

Question 32

Over half the people failing ESC and Seattle criteria had following abnormalities

Answer 32

``` Left or right atrial enlargement Left or right axis deviation RVH Complete RBBB or LBBB RVH with concomitant right axis deviation ```

Question 33

Refined 2014 QTC criteria

Answer 33

2.1% false positives white athletes | 10% false positives black athletes

Question 34

Left Axis Deviation

Answer 34

Lead 1 pointing up (leaving page) | Lead III pointing down (leaving page)

Question 35

Right Axis Deviation

Answer 35

Lead I pointing down | Lead III up (returning)

Question 36

Left atrial enlargement

Answer 36

Negative potion of P wave in lead V1>0.1mV in depth and >40ms in duration

Question 37

Right atrial enlargement

Answer 37

P wave amplitude >2.5mm in leads II, III or aVF

Question 38

RVH

Answer 38

Sum of R in V1 + S in V5 (or V6)>10mm

Question 39

Sudden cardiac death causes percentage- cardiomyopathy

Answer 39

41%

Question 40

Sudden cardiac death causes percentage- congenital and anatomic abnormalities

Answer 40

26%

Question 41

Sudden cardiac death causes percentage- electric disorders

Answer 41

10%

Question 42

Sudden cardiac death causes percentage- idiopathic hypertrophy

Answer 42

8%

Question 43

Sudden cardiac death causes percentage- acquired disorders

Answer 43

8%

Question 44

Sudden cardiac death causes percentage- valvular disorders

Answer 44

6%

Question 45

Sudden cardiac death causes percentage- coronary artery disease

Answer 45

1%

Question 46

Sudden cardiac death % below 17 (including)

Answer 46

65% | 59% in high school

Question 47

ATWI

Answer 47

In adult, white, asymptomatic individuals deemed normal if limited to V1-V2 Beyond V2 rare and should be investigated Preceded by J point depression or ST segment depression should also be investigated further

Question 48

ST depression

Answer 48

Rare | V bad

Question 49

Hypokalaemia early changes

Answer 49

Flattening or inversion of T waves Prominent U waves ST segment depression Prolonged QT interval

Question 50

Hypokalaemia late changes

Answer 50

Prolonged PR interval Decreased QRS voltage Widened QRS Ventricular arrhythmia

Question 51

Slow HR

Answer 51

Increased vagal tone Reduced intrinsic sinus pacemaker rate Reverses on detraining

Question 52

Slow HR- more likely to exhibit

Answer 52

Sinus bradycardia Junctional rhythm 1st degree heart block Mobitz type 1

Question 53

Mobitz type II and 3rd degree HB are

Answer 53

Rare | Further investigation