Athlete's ECG

Screening and risk stratification

The main goal of medical supervision in sports is the timely detection of individuals at high risk of sudden cardiac death (SCD). Physicians must maintain high clinical alertness, specifically looking for ECG and echocardiographic signs of hereditary arrhythmogenic diseases.

There is no consensus in global practice regarding the need for mass ECG screening of the entire population:

• Italy and Japan have positive experiences, where state ECG screening systems aimed at detecting asymptomatic genetic pathologies successfully operate.
• At the same time, data remain contradictory: a large-scale study in Israel demonstrated no real reduction in the incidence of SCD among professional athletes after the introduction of mandatory monitoring.

Nevertheless, screening professional athletes before competitions remains a strict requirement of the International Olympic Committee and is mandatory in Europe and the USA.

The examination is strictly regulated depending on age:

1. Athletes under 35: a thorough medical history, physical examination by a physician, and a standard 12-lead ECG are recommended.
2. Individuals over 35: before issuing clearance for high-intensity physical exertion, a specialist must perform a comprehensive assessment of cardiovascular risk (CVR).

It is important to note that cardiovascular examination is recommended for absolutely all participants before starting competitions. Competitive sports refer to any regular amateur or professional activity involving participation in organized contests.

Management of arrhythmias and regimen

The management strategy for athletes depends directly on the nature of the abnormalities detected on the ECG. When clinically significant ventricular arrhythmias (VA) are recorded, the athlete must be temporarily suspended from any physical activity.

• Detraining is indicated in such situations—a period of complete cessation of training lasting from 30 to 90 days, after which a repeat in-depth examination is performed.
• The prognosis is most often favorable: if the rhythm disturbances are exclusively associated with high athletic loads and are not caused by genetic factors, they resolve completely on their own.

Non-pharmacological treatment involves prescribing a strict conservative regimen. The volume of daily activities during this period should correspond to the classic concept of a "sedentary lifestyle".

• For regular patients in typical cases, it is sufficient to maintain such a regimen for only a few days—until the pain syndrome is relieved, body temperature normalizes, and C-reactive protein (CRP) levels decrease.
• For professional athletes, different rules apply. A prolonged conservative regimen is justified exclusively for them and must last for a minimum of 3 months.

Resumption of professional-level training is permitted only when three strict conditions are simultaneously met: persistent disappearance of clinical symptoms, complete normalization of inflammatory laboratory markers (CRP and ESR), and return of ECG and echocardiography parameters to normal.

Atrial fibrillation in athletes

The problem of atrial fibrillation (AF) development requires special attention in sports cardiology. The physician is obliged to inform the athlete that prolonged and high-intensity training itself can contribute to the manifestation of this pathology.

If AF has already been diagnosed in an athlete, medical monitoring must include several key aspects:

• Heart Rate (HR) Assessment: in every such athlete, ventricular rate must be assessed directly during physical activity. Clinical symptoms or Holter ECG monitoring data are used for assessment. The main goal of monitoring is to achieve safe target HR values.
• Surgical Treatment: to prevent arrhythmia recurrences, the patient may be recommended catheter ablation (CA) of the AF and atrial flutter substrate. In sports medicine, this procedure is considered primarily as a method for improving quality of life. It is important to understand that it is not a way to increase overall life expectancy or reduce stroke risk.
• Pharmacotherapy: when using oral antiarrhythmic drugs, such as propafenone, strict restrictions are imposed. The athlete is advised to refrain from sports activities for the entire duration of the AF episode and for an additional two drug half-lives.

To minimize any fatal risks at sports facilities, it is advisable to organize mandatory training for all staff in basic life support (BLS) skills and ensure rapid access to automated external defibrillators.

Class and exam questions

What else to study on this topic

• Organization of sports facility safety: BLS algorithms and the use of automated external defibrillators.
• Assessment of ventricular rate in athletes with atrial fibrillation based on Holter monitoring data.
• Echocardiographic signs of hereditary cardiomyopathies associated with the risk of sudden cardiac death.
• Indications for catheter ablation in atrial flutter in professional athletes.
• Differential diagnosis of physiological ECG changes and pathological rhythm disturbances during high loads.

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.