JACC: Clinical Electrophysiology
Electrocardiographic Features Differentiating Arrhythmogenic Right Ventricular Cardiomyopathy From an Athlete’s Heart
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Author + information
- Maria J. Brosnan, MD, PhDa,b,∗,
- Anneline S.J.M. te Riele, MD, PhDc,d,e,∗,
- Laurens P. Bosman, MDc,e,
- Edgar T. Hoorntje, MDf,
- Maarten P. van den Berg, MD, PhDf,
- Richard N.W. Hauer, MD, PhDe,
- Michael D. Flannery, MDa,i,
- Jon M. Kalman, MD, PhDh,i,
- David L. Prior, MD, PhDb,
- Crystal Tichnell, MGCd,
- Harikrishna Tandri, MDd,
- Brittney Murray, MSd,
- Hugh Calkins, MDd,†,
- Andre La Gerche, MD, PhDa,b,g,†∗ (andre.lagerche{at}baker.edu.au) and
- Cynthia A. James, PhD, ScMd,†
- aSports Cardiology Lab, Baker Heart and Diabetes Institute, Melbourne, Australia
- bDepartment of Cardiology, St. Vincent’s Hospital Melbourne, Fitzroy, Australia
- cDepartment of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
- dDepartment of Medicine, Division of Cardiology, Johns Hopkins University, Baltimore, Maryland
- eNetherlands Heart Institute, Utrecht, the Netherlands
- fDepartment of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
- gDepartment of Cardiovascular Medicine, University of Leuven, Leuven, Belgium
- hDepartment of Medicine, Royal Melbourne Hospital, University of Melbourne, Australia
- iDepartment of Cardiology, Royal Melbourne Hospital, Parkville, Australia
- ↵∗Address for correspondence:
Professor Andre La Gerche, Clinical Research Domain, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne 3004, Victoria, Australia.
Graphical abstract
Abstract
Objectives This study sought to compare electrocardiogram (ECG) variants in athletic and arrhythmogenic right ventricular cardiomyopathy (ARVC) cohorts matched for the confounders of age, sex, and ethnicity.
Background Anterior T-wave inversion (TWIV1−V4) is a common electrocardiographic finding in both athletes and patients with ARVC, and is a frequent conundrum in the setting of pre-participation screening. J-point elevation (JPE) has been proposed as an accurate means of identifying athletes, whereas disease markers, including premature ventricular contractions (PVCs) and low-voltage signals, have been associated with ARVC.
Methods This study examined 200 subjects with TWI V1−V4, including 100 healthy athletes and 100 ARVC patients matched 1:1 for age, sex, and ethnicity (age: 21 ± 5 years for athletes vs. 22 ± 5 years for ARVC patients; 47% male; 97% Caucasian). The presence of TWI, JPE, PVCs, and left ventricular hypertrophy (LVH) were assessed.
Results JPE was observed in 27% of athletes versus 16% of ARVC patients (p = 0.09). Thus, JPE had poor specificity (27%) and accuracy (60%) in identifying healthy athletes. In contrast, ARVC patients demonstrated a greater prevalence of precordial TWI beyond lead V3 (34% vs. 8%; p < 0.001), inferior TWI (31% vs. 3%; p < 0.001), PVCs (18% vs. 0%; p < 0.001), and lower LVH scores (SV1 + RV5; 19 ± 1 mm vs. 30 ± 1 mm; p < 0.001). These combined factors provided more reliable differentiation between health and disease (specificity 82%, accuracy 81%).
Conclusions PVCs and low QRS voltages are more prevalent among ARVC patients than athletes, whereas JPE is a relatively poor discriminator of health and disease when the confounders of age, sex, and ethnicity are considered.
- arrhythmogenic right ventricular cardiomyopathy
- athlete
- ECG
- pre-participation screening
- T-wave inversion
Footnotes
↵∗ Drs. Brosnan and te Riele contributed equally to this work and are first authors.
↵† Drs. Calkins, La Gerce, and James contributed equally to this work and are senior authors. Katja Zeppenfeld, MD, served as Guest Editor for this paper.
Dr. La Gerche is supported by a Career Development Fellowship from the National Health and Medical Research Council (NHMRC 1089039) and a Future Leaders Fellowship from the National Heart Foundation (NHF 100409) of Australia. Dr. te Riele is supported by the Dutch Heart Foundation (grant number 2015T58) and the University Medical Center Utrecht Fellowship Clinical Research Talent. Dr. Calkins is supported by the Leducq Foundation – RHYTHM Network. Dr. James is supported by the Netherlands Organisation for Scientific Research (NWO, visitor’s travel grant). Drs. te Riele, Bosman, Hoorntje, and van den Berg are supported by the Netherlands Cardiovascular Research Initiative, an initiative supported by the Netherlands Heart Foundation (CVON2012-10 PREDICT, CVON2014-40 DOSIS, and CVON2015-12 eDETECT). The Johns Hopkins ARVD/C Program is supported by the Dr. Francis P. Chiaramonte Private Foundation, the Leyla Erkan Family Fund for ARVD Research, the Dr. Satish, Rupal, and Robin Shah ARVD Fund at Johns Hopkins, the Bogle Foundation, the Healing Hearts Foundation, the Campanella family, the Patrick J. Harrison Family, the Peter French Memorial Foundation, and the Wilmerding Endowments. Dr. Calkins is a consultant for Medtronic Inc. and St. Jude Medical, and receives research support from Boston Scientific Corp. Dr. Tandri receives research support from Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received July 17, 2018.
- Revision received August 22, 2018.
- Accepted September 10, 2018.
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