Dear colleagues,
recently a Young female professional Volleyball Player was evaluated for licensing.
She has no Family history of CVD, channelopathy, sudden cardiac death or arrhythmia. No sudden infant death syndrome. She has no history of dizziness or fainting during stress or exercise, no Palpitation during exercise/stress or rest, no tachycardia during rest.
Lab testing showed minimal Elevation of CK and nt-proBNP (mostlikely due to exhaustfull Training a day Prior), normal Levels in CK-MB and Trop.
We conducted ECG at rest. This is her first ECG conducted ever, so we have no comparison whatsoever. Please note the ST-Sgement canges and T-Wave changes in multiple leads along with the QTc and the framentations.
During exercise testing conducted changes remain until max Levels to dissapear in recom for about 10 minutes and then reappear in the following. Same with QTc.
Cardiac echo showed good RV and LV function, rather thick septal wall (9mm), normal strain, no diastolic dysfunction, no valvular dysfunction, normal RVOT, no gradients in LVOT or RVOT.
a 24-h-3-lead-holter is beeing conducted at the Moment and will be presented soon.
In the mean time MRI without adenosine had been conducted showing no major or minor ARVD criterion nor HCM.
What are your thoughts on the case?
Thank you
Regards
I think the ascending ST-segment changes have no pathological significance.
Hi Dr. Benito,
Taking into account that the subject is a female professional athlete, a few resting ECG markers secondary to physical conditioning would be expected to be present.
Compared to other sports, like, long distance running, swimming, snow cross-country, and cycling, volley is a sport of moderate aerobic power. Volley athletes may reach 17-18 METs on average when well conditioned.
That being said, resting ECG does not stir me emotion. QRS complex is narrow, frontal axis is at 60°, PR normal, QTc normal. What is unexpected is the heart rate of 90 bpm, remarkably high for a well trained professional athlete. Also, I would expect more pronounced repolarization changes at rest, signs of conduction disturbance through the right bundle branch, and early repolarization aspect. Asymmetric T waves inversion are present in inferior and lateral walls, which are compatible with cardiac electrical remodeling secondary to long term training.
During exercise test, repolarization remained quite stable throughout the exercise stage, as she reached 200/bpm with 200 watts. In the firsts 90 s of the recovery stage, her heart rate dropped 29 bpm which is about Ok. T wave became positive until 5.5 min during recovery stage, as expected in subjects with ST-T findings on resting ECG, returning to baseline aspects afterwards. Cardiac MRI and Echo were unremarkable.
Looking at the resting and exercise ECG tracings, I would estimate her age of about 30 years old.
Considering both resting ECG findings and performance during stress test, and If the test was carried out following at least 72 h of exercise deprivation, she is not yet well conditioned.
The ambulatory ECG strip refers to a short episode of nonsustained SVT. It was not clear for me exactly when it happened, but apparently was during sleeping period at night, when a few more related episodes may have also happened. The upper lines above the strip present several surges of heart rate, indicating holter exam was carried out during a routine training period. The electrodes seem to have been disconnected for a long period of time and then reconnected. Also, the third lead is missing is the strip presented.
Supraventricular arrhythmia is a common findings in athletes who have undergone cycles of high physical conditioning for some time.
Sorry for this long comment.
Best regards.
Peace and blessings.
Dear colleague Paulo,
very distinguished reading!
you are right. One would exspect changes in ST-Segment, also due to RBBB configuration in young athletes.
Compared to other endurance athletes she is neither well trained nor is she looking at a long history of training, for she is 19 years and started just a couple of years ago.
What struck me was the changes all the way through V6, Qtc also arouse trace of suspicion. In general I see changes through V3, rarely V4 in juvenile athletes. In most cases changes in ST-Segment and T-Wave normalize during exercise testing, remaining "normal" for some time after testing. In this case changes remain stable during all levels just to normalize after testing for about 5 minutes as you stated correctly. The heart rate is due to "stress" and young age. Her baseline heart rate in holter was 52/min.
And yes, structural remodelling can be seen, taking into account her body height and weight, changes are not astonishing though.
Having taken all of this into account I decided to conduct cardiac MRI after documentation of a somewhat normal Echo (except septal wall).
We do find electric changes before structural changes like ARVD or HCM in about one to three athletes per year (we see 3000/year roughly).
Since we cannot conduct 12 lead holter, the changes in 3 lead holter (I printed only to leads) could also account for a slow tachycardia of ventricular origin (about 94/min) for adapted QRS duration is double the time of normal duration. In the end, neither one (supraventricular or ventricular) does render me emotional. It is during sleep. Another reason we should install 12-lead holter.
Thank you for your very distinguished thougts on the case...I think it is important to have as many views to get there....one reason most athletes we visit stay were they are...in sports.
Regards
She is 19 years. Looking at 10 years of moderate exercise.