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ECG changes in young competitive Indian athletes.

INTRODUCTION: Regular sports participation is encouraged by the medical community as it improves fitness and reduces cardiovascular morbidity and mortality. A large proportion of the young population participates in competitive or recreational sports activity. Cardiovascular exercise involves the use of large muscles in a repetitive fashion, activating muscle fibers programmed for endurance and utilizing a heart rate range anywhere from 40 to 85 percent of our maximum heart rate. When performing cardiovascular exercise, blood flow is directed toward working muscles and away from areas that aren't doing much (such as your arms during running, or the digestive tract). There is increased blood flow, and blood volume returning to the heart. As the heart registers a larger blood volume, over time the left ventricle adapts and enlarges. This larger cavity can hold more blood, and ejects more blood per beat, even at rest. Over time, with chronic cardio training, our resting heart rate drops because each beat delivers a bigger burst of blood, and fewer beats are needed. This takes work off your heart and is why cardio exercise is recommended for healthy heart. However, cardiovascular exercise can also produce stress.

If we get into over-training, we may hit a point where we are drowning in cortisol. This eventually leads to immune-suppression and fat gain around the abdomen and face. The heart adapts to this by increasing the thickness of the left ventricle wall. This thickness derived from chronic weight training is healthy, whereas the thickness from chronic high blood pressure is not. What's the difference? The healthy heart only has to work under pressure for two to three hours of strength training per week, whereas the heart with high blood pressure has to work 24 hours a day, seven days a week. The second heart may exhaust, whereas the healthy heart becomes stronger with a lower resting heart rate. Exercise also stimulates the production of new blood vessels. As we make more blood vessels, there are more places for blood to flow, which results in more efficient circulation. Cardiovascular exercise increases the number of new blood vessels while resistance training increases the size of those blood vessels. There will be a profound improvement in cardiovascular function. The basal heart rate decreases due to increased vagal tone. Stroke volume increases due to increased myocardial muscle mass. A trained subject achieves the required cardiac output during exercise mainly by increasing the stroke volume rather than by heart rate, where as an untrained individual achieves the same cardiac output mainly by increasing the heart rate.

MATERIALS AND METHODS: The Study included 50 young competitive male athletes of age group ranging from 16-30 years; All the Subjects are of Indian origin hailing from Hyderabad and Visakhapatnam undergoing training at Lal Bahadur Sastry Stadium at Hyderabad, Railway stadium at Secunderabad, Port Stadium at Visakhapatnam comparing with 50 normal healthy subjects with irregular sports activity.

Sedentary non-athlete individuals of same age groups were selected.

Criteria for primary selection: Daily physical exercise category of 3-4 hrs/day since the last 5 years and specially trained by coach or a trainer.

My study is done as per the European Society of Cardiology including the recommendations alongside history and physical examination the inclusion of a resting 12-lead electrocardiogram (ECG).

The Data was statistically analyzed using Graphpadsoftware, the data was compared using unpaired t test.

RESULTS:

Heart Rate: Normal 60-100 beats/min, Bradycardia< 60, Tachycardia>100
                   Normal    Bradycardia    Tachycardia

Athletes--50         37           13             --
Non-Athletes--50     49           --             1


26% of Athletes had Sinus bradycardia and none had tachycardia, Average Heart rate in this group was 66 beats/min, Tabular form above showed difference in men and women.

Among the Non-Athlete group 98%(49/50 subjects) showed normal heart rate and just 2% (1 subject) showed tachycardia changes.

PR Interval: (Normal PR Interval 120-200 msec): In athletes, 96%(48/50 subjects) showed PR intervals ranging from 120-200msec and 4%(2/50) showed increase in PR intervals time.

Among on athletes 100% subjects showed normal range of PR interval.
                       Normal       [arrow up]>    [arrow down]<
                   (120-200 msec)     200 msec        120 msec

Athletes--50             48              2               --
Non-Athletes--50         50              0               0


QRS Duration: Normally- The QRS wave's duration is 0.08-.12 sec (80-120msec).

Among athletes 14% (7/50) subjects showed increased QRS interval period, none had any momentum of decreased QRS intervals.

Among Non-athletes 2% (1/50) showed increased QRS interval, 2% (1/50) showed decreased QRS interval duration.
QRS Duration          Normal       [arrow up]>   [arrow down]<
                   (80-120 msec)    120 msec        80 msec

Athletes--50            43              7              0
Non-Athletes--50        48              1              1


QT INTERVAL: Normal QT is (0.36-0.44 s) equal to or below 0.40s (400msec). (4,5,7,8,10) Among athletes 50% (25/50) had prolonged QT interval. Average QT interval of this group is 401 msec, which exceeded the expected range of 400 msec.

Non-of the Non-Athletic group had any prolonged or decreased QT interval, the average QT interval is being 351msec.
QT Interval            Normal       [arrow up]>   [arrow down]<
                   (360-120 msec)    120 msec        80 msec

Athletes--50             43              7              0
Non-Athletes--50         48              1              1


Corrected QT interval (QTc):

* Borderline "QTc" in males is 431-450 ms, and in females 451-470 msec.

* An "abnormal" QTc in males is a QTc above 450 ms, and in females, above 470 ms.

* Athletes showed any average QTc intervals of 420 msec which is within normal range, but 4% (2/50) male athlete subjects showed increased level of QTc interval.

All Non-athlete subjects were well in normal range in this duration.
 QTc Interval     Normal     [arrow up]
                            Increased QTc

 Athletes -50       48            2
Non-Athletes-50     50            0


AXIS: A normal heart axis is between -30 and +90 degrees.

[ILLUSTRATION OMITTED]

* A left heart axis is present when the QRS in lead I is positive and negative in II and AVF. (between -30 and -90 degrees)

* A right heart axis is present when lead I is negative and AVF positive. (Between +90 and +180).

Among Athletes 16% (8/50) subjects showed Left Axis deviation (LAD), 4% (2/50) showed Right Axis Deviation (RAD).

Among Non-Athletes 4% (2/50) subjects showed Left axis deviation (LAD), 2% (1/50) showed Mild Right deviation of axis diagnosed to have RBBB (RAD).

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

DISCUSSION: The interpretation of the athlete's ECG is often left to personal experience and usually made according to traditional ECG criteria used in the general (non-athletic) population.

Electrocardiogram changes in athletes are common and usually reflect structural and electrical remodeling of the heart as an adaptation to regular physical training (athlete's heart).

[ILLUSTRATION OMITTED]

IN THIS STUDY: Among the Athletes, 26% had Sinus bradycardia, none with tachycardia, Average Heart rate in this group was 66 beats/min.

Among the Non-Athletic group 98%(49/50 subjects) showed normal Heart Rate and just 2% (1 subject) showed tachycardia changes.

Bradycardia is the result of physiological adaptive changes of the autonomic nervous system and reflects the level of athletic conditioning. Only profound sinus bradycardia and/or marked sinus arrhythmia (heart rate < 30 beats/min and or pauses 3sec during wake hours) need to be distinguished from sinus node disease. Sino atrial node dysfunction can be reasonably excluded by demonstrating that: (i) Symptoms such as dizziness or syncope are absent;(ii)Heart rate normalizes during exercise, sympathetic maneuvers or drugs, with preservation of maximal heart rate, and (iii) Bradycardia reverses with training reduction or discontinuation. But few old athletes tend to complain of decreased heart rate might continue all their life even after they discontinue active sport and continue to work up at the least exercise levels to maintain standard of life. Few trainers now who were long standing athletes have complains of some discomfort if exercise levels are lowered with age building up with them. One of this being Sports Medicine Specialist and a boxer himself and a participant in national boxing championship 30 years back has an everlasting complaint of dizziness/syncopal attacks when resting or out of sports activity for more than 2 or 3 days, he retains his normal healthy status after he begins to exercise getting back to his practice.

D'Souza A (1) et al supported in their study that training-induced bradycardia is not a consequence of changes in the activity of the autonomic nervous system but is caused by intrinsic electrophysiological changes in the sinus node so concluded Exercise training reduces resting heart rate via down regulation of the funny channel HCN4.

Farahani B (4) et al in their study, Prevalence of different electrocardiographic patterns in Iranian athletes, explored the abnormalities in Iranian athletes electrocardiogram to find any relation with body fat. 239 international athletes were involved in this cross sectional study. Body-fat percentage and resting 12-lead ECGs were recorded from all participants. Of 239 participant athletes, 212 were male and 27 female. 60% of participants had sinus bradycardia.

ATRIO-VENTRICULAR BLOCK: First-degree AV block and Mobitz Type-I (Wenkebach) second degree AV block are common in trained athletes, and 2% (1/50) of athlete's ECGs respectively. As with sinus bradycardia, AV conduction slowing and block are mediated by increased parasympathetic tone or by decreased sympathetic tone. A very rare finding of Second-degree Mobitz Type-II and Type-III degree heart block in athletes to confirm that's it is due to cardiac adaptation activity.

Doutreleau S (2) et alin their study of Exercise-induced second-degree atrioventricularblock in endurance athletes.

Training induces volume- and time-dependent morphological and functional changes in the heart. Heart rhythm disorders, such as atrial arrhythmia (including atrial fibrillation and atrial flutter), are a well-established consequence of such long-term endurance practice. Although resting bradycardia and first-degree atrioventricular block persist in veteran athletes, higher conduction system impairment has never been reported neither at rest nor during exercise.

ISOLATED INCREASE OF QRS VOLTAGES: Intensive athletic activity causing morphological cardiac changes, including increased cavity dimensions, wall thickness and ventricular mass which is reflected in the 12-lead ECG. Physiological LV hypertrophy in trained athletes usually manifests as an isolated increase of QRS amplitude, with normal QRS axis normal atrial and ventricular activation patterns. Criteria for LV hypertrophy has been reported in trained athletes as its noticed here in one of the subject, which has increased QRS voltage and diagnosed to have LVH.

These subjects have been correlated ECG changes with cardiac morphology assessed by echocardiography. The ECG was labeled as 'abnormal' in (40%) athletes; however anisolated increase of QRS voltage accounted for 14% (7/50) of such changes. No athletes with isolated increase of QRS voltages had evidence of structural heart disease such as HOCM (Hypertrophic Obstructive Cardio Myopathy) in this workup but rather many athletes had been discovered to have diagnosed with HOCM.

Athletes who show pure QRS voltage criteria for LV hypertrophy on 12-lead ECG do not require systematic echocardiographic evaluation, unless they have relevant symptoms, a family history of cardiovascular diseases and or sudden cardiac death (SCD) or non-voltage ECG criteria suggesting any pathological LV hypertrophy.

Pelliccia A (3) et al in their study showed that highly trained athletes show morphologic cardiac changes (i.e, athlete's heart) that are the consequence of several determinants, including type of sport, gender, and, possibly, inherited genetic factors. The extent of physiologic cardiac remodeling may occasionally be substantial in highly trained athletes and may raise a differential diagnosis with structural cardiac disease, such as cardiomyopathies. In addition, athletes demonstrate a spectrum of alterations in the 12-lead electrocardiogram (ECG) pattern, including marked increase in precordial R-wave or S-wave voltages, ST segment or T-wave changes, and deep Q waves suggestive of left ventricular hypertrophy, that may raise the possibility of pathologic heart condition, but have also been viewed as a consequence of the cardiac morphologic remodeling induced by athletic conditioning. To evaluate the clinical significance of these abnormal ECGs, the authors compared ECG patterns to cardiac morphology and function (assessed by two-dimensional echocardiography in individual athlete) in a large population of 1005 elite athletes engaged in a variety of sporting disciplines. Forty percent of the athletes had abnormal ECGs, and a subgroup of about 15% showed distinctly abnormal and often bizarre patterns highly suggestive of cardiomyopathies, such as hypertrophic cardiomyopathy, in the absence of pathologic cardiac changes. Such alterations are likely the consequence of athletic conditioning itself and represent another potential component of athlete's heart syndrome.

INCOMPLETE RIGHT BUNDLE BRANCH BLOCK: The Prevalence of incomplete right bundle block (RBBB) (QRS duration 120 ms) has been estimated to range from 4% in athletes compared with less than 2% in young sedentary controls. This ECG pattern is more often noted in athletes engaged in endurance sports. It has been suggested that the right ventricular (RV) conduction delay is not within the specialized conduction system, but is caused by the enlarged RV cavity size /Increased cardiac muscle mass and the resultant increased conduction time. The RBBB morphology has been shown to be reversible with deconditioning.

EARLY REPOLARIZATION: Early repolarization has traditionally been regarded as an idiopathic can be benign ECG phenomenon, with an estimated prevalence in healthy young individuals of 1-2%, and a clear male preponderance. The early repolarization ECG pattern is the rule rather than the exception among highly trained athletes, in whom it is observed in 50-80% of resting ECGs. The early repolarization ECG shows elevation of the QRS-ST junction (J-point)of atleast 0.1mV from the baseline, associated with notching or slurring of the terminal QRS complex which may vary in location, morphology and degree.

Slowing of heart rate exaggerates ST-segment elevation, whereas sinus tachycardia occurring during exercise. Early repolarization in athletes reflects the development of a training related hypervagotonia, and ECG abnormalities are reversible phenomenon which reduces or disappears with deconditioning.

Early repolarization is a physiological and benign ECG pattern in the general population of younger people and athletes and does not require further evaluation.

But none of the ECG's in athletes showed any early repolarization changes.

ECG abnormalities with the cardiovascular diseases include repolarization abnormalities such as inverted T-waves and ST-segment depression, pathological Q wave conduction disease including left-axis deviation, ventricular pre-excitation, long-and short QT interval and Brugada-like repolarization changes.

Unlike the ECG changes characteristic of athlete's heart, such ECG abnormalities are relatively uncommon (5%) and training-unrelated. Further diagnostic work-up is mandatory for those athletes who exhibit such ECG changes in order to confirm (or exclude) an underlying cardiovascular disease.

De Asmundis C5 et al in their study of Prevalence and electrocardiographic characteristics of early repolarization pattern (ERP) in young teen athletes, Of the 122 included subjects, The overall prevalence of ERP in their study population was 36%, Interestingly, incomplete right bundle-branch block (IRBBB) was significantly lower among all subjects with ERP (N = 15; 34.1%), compared to those without ERP (N = 49; 63%) (P < 0.002). And henceforth concluded that ERP is a common finding in young teen athletes.

LEFT VENTRICULAR HYPERTROPHY: Electrocardiogram offers the potential to distinguish between pathological and physiological hypertrophy, given that ECG abnormalities of structural heart diseases manifesting with LV hypertrophy, such as cardiomyopathies, valve diseases, or hypertensive heart disease overlap only marginally with training-related ECG changes.

One of the Athletes namely subject number 28 has shown changes of LVH in ECG as:

* Markedly increased LV voltages: Huge precordial R and S waves that overlap with the adjacent leads (SV2 + RV6 " 35 mm).

* R-wave peak time > 50 ms in V5-6 with associated QRS broadening.

* LV strain pattern with ST depression and T-wave inversions in I, aVL and V5-6.

* ST elevation in V1-3.

* Prominent U waves in V1-3.

* Left axis deviation.

Diagnosed as Sinus Rhythm with LVH as this subject was send for further investigations ECHO test, a procedure of choice for LVH, showed changes as concentric Left Ventricular Hypertrophy, Ejection Fraction is 70%, and no systolic dysfunction seen. So likewise an athletes heart is a growing extra thick as if it is under constant stress and need extra thickened muscle to provide the strength to pump out blood sufficiently to the peripheral parts, so this is usually a life style effect in athletes and most of the times not life threatening.

Arbab-Zadeh A (6) et al. Cardiac Remodeling in Response to 1 year of Intensive Endurance training One year of prolonged and intensive endurance training leads to cardiac morphologic adaptations in previously sedentary young subjects similar to those observed in elite endurance athletes; however it is not sufficient to achieve similar levels of cardiac compliance and performance. Contrary to conventional thinking, the left ventricle responds to exercise with initial concentric not eccentric remodeling during the first 6-9 months after commencement of endurance training depending on the duration and intensity of exercise. Thereafter, the left ventricle dilates and restores the baseline mass to volume ratio. In contrast, the right ventricle responds to endurance training with eccentric remodeling at all levels of training.

Caselli S (7) et al Differentiating left ventricular hypertrophy in athletes from that in patients with hypertrophic cardiomyopathy.

Aimed in the study was to revise the ability of simple echocardiographic and clinical variables for the differential diagnosis of HC versus athlete's heart. Twenty-eight athletes free of cardiovascular disease were compared with 25 untrained patients with HC, matched for LV wall thickness (13 to 15 mm), age, and gender. Clinical, electrocardiographic, and echocardiographic variables were compared. Athletes had larger LV cavities (60 [+ or -] 3 vs 45 [+ or -] 5 mm, p <0.001), aortic roots (34 [+ or -] 3 vs 30 [+ or -] 3 mm, p <0.001), and left atria (42 [+ or -] 4 vs 33 [+ or -] 5 mm, p <0.001) than patients with HC. LV cavity <54 mm distinguished HC from athlete's heart with the highest sensitivity and specificity (both 100%, p <0.001). Left atrium >40 mm excluded HC with sensitivity of 92% and specificity of 71% (p <0.001)

ST SEGMENT DEPRESSION: Although ST segment elevation due to early repolarization is a common finding in the basal ECG of trained athletes, resting ST segment depression is rarely observed, none of the subjects showed any changes in ST segment.

RIGHT ATRIAL ENLARGEMENT AND RIGHT VENTRICULAR HYPERTROPHY: ECG evidence of right atrial enlargement and/ or RV hypertrophy is uncommon finding in athletes. The presence of either congenital or acquired heart diseases associated with an increased right atrial size and/or pathological RV dilatation/ hypertrophy should be excluded.

T-WAVE INVERSION: Recent studies on large athletic populations disproved the traditional idea that T-wave inversions are common and training-related ECG changes in the athlete.

T-wave inversion in young and apparently healthy athletes may represent the initial phenotypic expression of an underlying cardiomyopathy prior to the development of morphological changes detectable on cardiac imaging.

T-wave inversions 2 mm in two or more adjacent leads is rarely observed on the ECG of healthy athletes, where as it is a common finding in patients with cardiomyopathy and other cardiac disease.

VENTRICULAR PRE-EXCITATION (WOLFF- PARKINSON-WHITE): None of the subjects were found to have any WPW abnormalities.

They prevalence of ventricular pre-excitation in the general population varies from 0.1% to 0.3% and is similar in athletes. Most individuals with WPW pre-excitations syndrome remain asymptomatic throughout their lives. When symptoms do occur, they are usually secondary to reciprocating supraventricular tachycardia which causes disabling symptoms.

LONG-QT INTERVAL: The duration of the QT interval(i.e.the interval between the beginning of the QRS complex and the end of the T-wave) changes with heart rate and it is usually corrected (QTc) by using,

Bazett's formula [QT.sub.B] = QT/[square root of (RR)]

QT INTERVAL: Normal QT is (0.36-0.44 s) equal to or below 0.40s. (400msec).

Among athletes 50% (25/50) had prolonged QT interval. Average QT interval in this group being 401 msec, which has over leaped the expected range of 400 msec.

Among the Non-Athletes nobody had any prolonged or decreased QT interval, in this group average QT intervals being 351msec.

The QT interval should be measured in L2,V3, or V5;the longest value (return to baseline)should be considered.

The calculation of the QT interval in athletes has inherent limitations due to sinus arrhythmia, slightly widened QRS complexes and T-U complexes. Corrections for heart rate may be in accurate at heart rates below 40and above 120 bpm.

QT interval is modulated by gender and therefore different cut off values are used after puberty. A QTc interval is traditionally considered long in men when it is more than 440 ms and in women when it exceeds 460 ms, but some suggested values upto and above 470 ms in males and 480 ms in female.

In general QT interval is longer in athletes than in non-athletic control because of the lower resting heart rate associated with athletic training, and this workup has demonstrated the average QT interval in Indian athletes is 401ms, whereas average QT interval in Non-athletes is 351ms, while the QTc of the athletic group is within normal limits, though toward the upper limit.

Recording of QTc intervals beyond the normal cut-off values should raise the suspicion of either acquired or congenital long QT syndrome (LQTS).

Omiya K (8) et al Influence of gender and types of sports training on QT variables in young elite athletes. Influence of gender and sports training on QT variables such as QT interval and dispersion (QT dispersion: QTD) in young elite athletes were evaluated.

Concluded Maximum and minimum QTc were significantly longer in female athletes than in male athletes (max: 414.2 vs. 404.5 ms, min: 375.1 vs. 359.2 ms, p<0.0001 respectively), whereas QTc dispersion (QTcD) was shorter in female athletes than in male athletes (39.2 vs. 45.3 ms, p<0.0001). QTcD was significantly shorter in female athletes than in the female control group (39.2 vs. 45.2 ms, p<0.05). However, no statistically significant difference was observed between male athletes and the male control group. Male gymnasts exhibited significantly longer QTcD than the control group (p<0.01), but female gymnasts had significantly shorter QTcD than the control group (p<0.05). Maximum QTc intervals were prolonged in the male static training group compared with non-athletes, and QTcDs in the static training group were prolonged compared with the endurance training group. However, no significant difference was observed in the female group. In conclusion, both gender and different characteristics of sports training may affect QT variables even in young elite athletes. Vigorous static exercise training may independently prolong QT variables.

Griffet V9 et al in their workup of Athlete's heart in the young, while recording the ECG and echocardiographic patterns in 107 French athletes and hence concluded Adolescent athlete's heart is normal. If QTc interval is not normal, be afraid of a QT long syndrome. Furthermore, when interventricular septal thickness is > 11 mm or left ventricular end diastolic diameter > 55 mm, myocardiopathy will have to be ruled out.

CONCLUSION: Now after determining ECG changes which are physiological (common and training-related ECG abnormalities) and that which are pathological (uncommon and training-unrelated ECG abnormalities) is expected to reduce the traditional high number of false positives, so wise reducing the investigations. (11)

In this study, the ECGs were classified into three subgroups, as distinctly abnormal, mildly abnormal, and normal (or with minor alterations).

Abnormal ECG was identified in (6%) athletes of which distinctly abnormal in 2% (1/50), and mildly abnormal in 4% (2/50).

In the remaining 94% athletes (47/50), ECGs were normal in or exhibited only minor alterations, which were deemed typical of the athletes heart, of the 3 athletes with ECG abnormalities previously classified as abnormal and suggestive of cardiac disease, 1 case exhibited an isolated increase of QRS voltage.

But this workup will be helpful in making certain rules in our country to bring up the compulsory pre-participation screening program for upcoming athletes in schools (while on the go certain sports schools have already taken up this screening program voluntarily) and to prevent and early diagnosis of cardiac diseases.

DOI: 10.14260/jemds/2015/99

REFERENCES:

(1.) D'Souza A, Bucchi A, Johnsen AB, Logantha SJ, Monfredi O, Yanni J,et al..: Exercise training reduces resting heart rate via down regulation of the funny channel HCN4.-Nat Commun. 2014 May 13; 5: 3775. doi: 10.1038/ncomms4775.

(2.) Doutreleau S1, Pistea C, Lonsdorfer E, Charloux A: Exercise-induced second-degree atrioventricular block in endurance athletes -Med Sci Sports Exerc. 2013 Mar; 45 (3): 411-4. doi: 10.1249/MSS.0b013e318276c9a4.

(3.) PellicciaA (1), Di Paolo FM, Maron BJ:The athlete's heart: remodeling, electrocardiogram and preparticipation screening. In Cardiol -Rev. 2002 Mar-Apr; 10 (2): 85-90.

(4.) Farahani B (1), Poursaeid Esfahani M, Abbasi MA, Moradi F, Abbasi A:Prevalence of different electrocardiographic patterns in Iranian athletes -Acta Med Iran. 2012; 50 (8): 560-4.

(5.) De Asmundis C, Conte G, Levinstein M, Chierchia GB, Sieira J, Di Giovanni G, Baltogiannis G, Park MH, Sarkozy A, Brugada P: Prevalence and electrocardiographic characteristics of early repolarization pattern in young teen athletes-Acta Cardiol. 2014 Feb; 69 (1): 3-6.

(6.) Arbab-Zadeh A, Perhonen M, Howden E, Peshock RM, Zhang R, Adams-Huet B, Haykowsky MJ, Levine BD: Cardiac Remodeling in Response to 1 Year of Intensive Endurance Training. Circulation. 2014 Oct 3.pii: CIRCULATIONAHA.114.010775.

(7.) Caselli S (1), Maron MS (2), Urbano-Moral JA (2), Pandian NG (2), Maron BJ (3), Pelliccia A (4): Differentiating left ventricular hypertrophy in athletes from that in patients with hypertrophic cardiomyopathy-Am J Cardiol. 2014 Nov 1; 114 (9): 1383-9. doi: 10.1016/j.amjcard.2014.07.070. Epub 2014 Aug 12.

(8.) Omiya K (1), Sekizuka H, Kida K, Suzuki K, Akashi YJ, OhbaH, Musha H: Influence of gender and types of sports training on QT variables in young elite athletes--.ur J Sport Sci. 2014; 14Suppl 1: S32-8. doi: 10.1080/17461391.2011.641032.

(9.) Griffet V (1), Finet G, Di Filippo S, Lantelme P, Caignault JR, Guerard S.:Athlete's heart in the young: electrocardiographic and echocardiographic patterns in 107 French athletes-Ann Cardiol Angeiol (Paris). 2013 Apr; 62 (2): 116-21. doi: 10.1016/j.ancard.2013.02.003.

(10.) Vernuccio F, Grutta G, Fazio G: Sudden cardiac death in athletes: is it always not preventable.Recenti Prog Med. 2014 Nov; 105 (11): 410-4. doi: 10.1701/1680.18400.

(11.) Assanelli D (1), Levaggi R, Carre F, Sharma S, Deligiannis A, Mellwig KP, Tahmi M, Vinetti G: Cost-effectiveness of preparticipation screening of athletes with ECG in Europe and Algeria. --Aliverti PIntern Emerg Med. 2014 Aug 28.

M. Padma Geethanjali [1], P. S. N. Raju [2], V. Seetharama Raju [3]

AUTHORS:

[1.] M. Padma Geethanjali

[2.] P. S. N. Raju

[3.] V. Seetharama Raju

PARTICULARS OF CONTRIBUTORS:

[1.] Professor & HOD, Department of Physiology, Andhra Medical College, Visakhapatnam.

[2.] Assistant Professor, Department of Physiology, Andhra Medical College, Visakhapatnam.

[3.] Assistant Professor, Department of Physiology, Andhra Medical College, Visakhapatnam.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. P. S. N. Raju, # 39-6-47, Flat No. 201, Leela Residency, Muralinagar, Visakhapatnam, Andhra Pradesh-530007.

E-mail: doctorraju@yahoo.com

Date of Submission: 19/12/2014.

Date of Peer Review: 20/12/2014.

Date of Acceptance: 02/01/2015.

Date of Publishing: 10/01/2015.
Table 1: Master sheet Athletes ECG Values

SL.   Name    Age   Sex    HR         P
No.                                 Durat

1      RK     26     M     62        108

2      SS     26     M     50        101

3      RA     26     M     54     [arrow up]
                                     123

4      PN     26     M     70        110

5      RK     25     M     55        102

6      SS     23     M     68        112

7      SD     24     M     74        112

8      BS     28     M     76        108

9       V     27     M     54         96

10     VR     21     M     73     [arrow up]
                                     121

11     PA     24     M     70        117

12     JR     27     M     67     [arrow up]
                                     130

13     SA     25     M     61        120

14     PI     24     M     66     [arrow up]
                                     141

15     SFR    23     M     60        106

16     PRR    25     M     69        100

17     SW     23     M     73     [arrow up]
                                     141

18     MH     17     M     67     [arrow up]
                                     130

19     AY     20     M     54         96

20     GV     21     M     63        104

21     PR     16     M     78        108

22     MS     26     M     63     [arrow up]
                                     121

23     Ps     27     M     45        111

24     PSa    23     M     55     [arrow up]
                                     121

25     PM     21     M     69     [arrow up]
                                     124

26     BP     24     M     59        108

27     TV     26     M     49     [arrow up]
                                     129

28     UA     23     M     65     [arrow up]
                                     140

29     MF     28     M     81        109

30     KV     20     M     59     [arrow up]
                                     161

31     SS     26     M     62     [arrow up]
                                     126

32     PS     25     M     48         13

33     JK     24     M     82        102

34     Sm     24     M     63     [arrow up]
                                     152

35     KV     25     M     62         98

36      R     21     M     52         93

37     RS     19     M     68        112

38     Pk     21     M     72        106

39     TR     22     M     76        111

40     BS     23     M     68        103

41     BP     23     F     70        111

42     TB     24     F     73        106

43     SY     22     F     74        112

44     PP     23     F     80         98

45     SJ     19     F     81        101

46     JS     23     F     68        107

47     CJ     21     F     76        112

48      M     20     F     80        111

49     SL     19     F     81        104

50     KP     24     F     59        101

SL.                Intervals              T      QTc
No.       PR          QRS        QT     Durat

1        122           82        390     206     382

2        132           81       1470     194     429

3        192           96       1453     202     430

4        145           82        407     235     440

5        120          101        425     212     410

6        155           87        410     215     439

7        130           97        370     195     411

8        121           90        420     212     473

9        156       [arrow up]    446     201     422
                      128

10       153           88        378     211     417

11       170           97        397     197     429

12    [arrow up]       92        420     265     443
         204

13       152           95        417     237     422

14       188          106        424     221     445

15       124           87        425     206     425

16       148           83        403     199     433

17       181       [arrow up]    391     203     432
                      136

18       177          100        397     265     420

19       156       [arrow up]    446     204     422
                      128

20       132           80        401     196     411

21       132           76        348     208     397

22       174          103        390     222     400

23       168          109        418     219     362

24       144          112        411     215     394

25       181          103        391     240     419

26       132           68        408     214     405

27       152           98        407     221     388

28       172       [arrow up]    414     231     459
                      136

29       132           94        378     219     439

30    [arrow up]   [arrow up]    448     226     443
         201          125

31       141          104        400     229     404

32       168       [arrow up]    469     209     374
                      131

33       126           94        388     216     454

34       187           97        412     225     423

35       109           83        391     201     398

36       109       [arrow up]    378     206     405
                      121

37       131           91        371     209     395

38       128           88        378     216     415

39       136           92        385     221     434

40       132           86        401     208     427

41       154           87        378     211     408

42       121           96        404     221     446

43       128           89        367     203     408

44       123           83        363     208     419

45       121           89        374     224     435

46       121           98        391     219     416

47       136          101        386     231     434

48       128           93        344     219     397

49       126           89        364     216     423

50       116           91        408     221     405

SL.         Axis                 Remarks
No.

1       47[degrees]

2       28[degrees]         Sinus Bradycardia

3       62[degrees]         Sinus Bradycardia

4     -44[degrees] -Lt

5       64[degrees]         Sinus Bradycardia

6     36[degrees] -Lt

7       38[degrees]

8       -60[degrees]

9     -48[degrees] -Lt   Sinus Bradyc, RBBB,LAD

10      40[degrees]

11      72[degrees]

12      60[degrees]        1[degrees] AV Block

13      55[degrees]

14    -75[degrees] -Lt

15      -10[degrees]

16    -22[degrees] -Lt

17    110[degrees] Rt        Incomplete RBBB

18      -36[degrees]

19    -45[degrees] -Lt      Sinus Bradycardia

20       0[degrees]

21      -10[degrees]

22      25[degrees]

23      12[degrees]         Sinus Bradycardia

24      28[degrees]         Sinus Bradycardia

25      65[degrees]

26      10[degrees]         Sinus Bradycardia

27      26[degrees]         Sinus Bradycardia

28    -45[degrees] -Lt   Lt Ventricular Hypertro

29      10[degrees]

30      120[degrees]        Sinus Bradycardia

31      18[degrees]

32      30[degrees]         Sinus Bradycardia

33    -50[degrees] -Lt

34      -20[degrees]

35       0[degrees]

36      18[degrees]         Sinus Bradycardia

37      22[degrees]

38      10[degrees]

39      -12[degrees]

40       0[degrees]

41      10[degrees]

42    -36[degrees] -Lt

43      28[degrees]

44      18[degrees]

45      -20[degrees]

46      12[degrees]

47       0[degrees]

48      20[degrees]

49      -15[degrees]

50      28[degrees]         Sinus Bradycardia

Table 2: Master sheet NON Athletes ECG Values

SL.   Name   Age    Sex     HR     P              Intervals
No.                               Durat
                                           PR        QRS       QT

1      P      21     M      82     111     139       89        331
2      S      25     M     101     108     138       90        327
3      A      25     M      83     116     141       90        339
4      S      23     M      73     90      131       77        362
5      R      28     M      93     115     134       95        338
6      G      26     M      85     122     157       85        345
7      P      25     M      81     108     135       96        349
8      K      21     M      67     141     162      T129       391
9      S      25     M      87     120     159       88        340
10     P      20     M      86     118     153       91        377
11     J      17     M      72     98      128       81        361
12     S      16     M      74     115     140       96        375
13     P      21     M      86     113     142       98        334
14     P      24     M      80     107     136       96        354
15     C      23     M      68     111     139       86        331
16     R      20     M      78     119     146       92        341
17     S      21     M      72     108     144       91        389
18     M      21     M      75     117     140       100       371
19     K      23     M      82     106     129       80        351
20     V      28     M      73     101     132       69        387
21     K      25     M      90     110     141       91        329
22     C      16     M      89     108     139       91        331
23     G      19     M      80     109     121       84        361
24     C      19     M      73     121     154       96        352
25     G      23     M      81     110     131       94        361
26     K      26     M      80     113     148       96        348
27     E      20     M      71     118     142       91        334
28     V      22     M      78     116     140       88        346
29     K      21     M      76     108     131       90        368
30     D      25     M      68     112     139       96        363
31     R      20     M      80     106     121       81        341
32     S      23     M      78     116     136       90        339
33     A      23     M      84     101     128       90        336
34     N      17     M      78     102     124       88        363
35     P      19     M      72     98      141       81        385
36     S      26     M      62     112     138       84        390
37     S      26     M      78     110     149       98        378
38     J      26     M      73     112     144       78        361
39     P      25     M      72     116     152       92        345
40     S      26     M      88     112     142       90        324
41     K      24     F      89     108     150       84        321
42     G      18     F      84     106     136       80        329
43     T      20     F      91     110     153       80        328
44     S      25     F      82     114     150       91        342
45     K      22     F      81     118     148       89        349
46     V      19     F      70     107     131       86        352
47     M      18     F      76     108     128       91        346
48     K      21     F      84     111     132       93        332
49     A      24     F      80     106     124       88        361
50     S      21     F      86     102     120       91        330

SL.   T Durat   QTC        QRS Axis           Remarks
No.

1       203     387       36[degrees]
2       162     424       30[degrees]      Sinus Tachycar
3       208     399    -45[degrees] -Lt
4       201     399       40[degrees]
5       215     421     -6[degrees] -Lt
6       204     410       25[degrees]
7       125     405       20[degrees]
8       217     413    110[degrees] -Rt         RBBB
9       201     388       35[degrees]
10      221     421       25[degrees]
11      203     396       45[degrees]
12      226     417       48[degrees]
13      216     400       45[degrees]
14      208     409       30[degrees]
15      202     352       60[degrees]
16      210     389       30[degrees]
17      232     426       22[degrees]
18      201     415       55[degrees]
19      206     410       45[degrees]
20      192     405       60[degrees]
21      222     403       15[degrees]
22      216     403       45[degrees]
23      206     417       30[degrees]
24      221     388       26[degrees]
25      221     420       42[degrees]
26      221     402       48[degrees]
27      208     363       35[degrees]
28      217     395       45[degrees]
29      212     414       20[degrees]
30      208     386       40[degrees]
31      210     394       15[degrees]
32      212     387      -10[degrees]
33      211     398       28[degrees]
34      206     414       75[degrees]
35      212     422       60[degrees]
36      208     395       30[degrees]
37      221     410       48[degrees]
38      216     398       64[degrees]
39      208     378       46[degrees]
40      202     393       52[degrees]
41      208     391       50[degrees]
42      205     389       10[degrees]
43      201     404      -22[degrees]
44      208     400       50[degrees]
45      216     406       45[degrees]
46      215     380       56[degrees]
47      220     389       18[degrees]
48      218     393       12[degrees]
49      212     417       72[degrees]
50      203     395       35[degrees]

Table 3: Changes in the ECG of 50 Athletes

Analyzed ECG changes                        Number of
                                          patients, n (%)

Sinus bradycardia< 60/min                    13 (26%)
Severe sinus bradycardias                      0(0%)
  [less than or equal to] 40/min
Prolonged QT interval                          2(4%)
Prolonged QTc interval as per Bazett's         0(0%)
Ventricular Arrhythmias                        0(0%)
Shortened PR interval < 120 ms                 0(0%)
Prolonged PR Interval > 200 ms                 2(4%)
Left bundle branch block                       0(0%)
Right bundle branch block                      2(4%)
Heart Axis Deviation QRS > -30[degrees]       39(78%)
Right Axis Deviation > +90[degrees]            2(4%)
Left Axis Deviation < -30[degrees]            9(18%)
Incomplete RBBB                                1(2%)
Early Repolarization                           0(0%)
Isolated Voltage for Left Ventricular          1(2%)
  Hypertrophy
Features of left atrial hypertrophy            0(0%)
T Wave inversions(negative T wave)             0(0%)
R wave in V5 or V6 > 3.0 mV                    1(2%)
S wave in V1 or V2 > 3.0 mV                    1(2%)

Figure 3
Athletes Age vs Heart Rate
Age Wise Heart Rate changes in Athletes

Age   Heart Rate

26       62
26       60
26       54
26       70
25       55
23       68
24       74
28       76
27       54
21       73
24       70
27       67
25       61
24       66
23       60
25       69
23       73
17       67
20       54
21       63
16       78
26       63
27       45
23       55
21       69
24       59
26       49
23       65
28       81
20       59
26       62
25       48
24       82
24       63
25       62
21       52
19       68
21       72
22       76
23       68
23       70
24       73
22       74
23       80
19       81
23       68
21       75
20       80
19       81
24       59

Note: Table made from bar graph.

Figure 4
Non Athletes Age vs Heart Rate
Age wise changes in Heart Rate of Non Athletes

Age   Heart Rate

21       82
25       101
25       83
23       73
28       93
26       85
25       81
21       67
25       87
20       86
17       72
16       74
21       86
24       80
23       68
20       78
21       72
21       75
23       82
28       73
25       90
16       89
19       80
19       73
23       81
26       80
20       71
22       78
21       76
25       68
20       80
23       78
23       84
17       78
19       72
26       62
26       78
26       73
25       72
26       88
24       89
18       84
20       91
25       82
22       81
19       70
18       76
21       84
24       80
21       86

Note: Table made from bar graph.

Figure 5
Bar Chart showing Average Heart Rate
In Athletes and Non Athletes

               Heart Rate

Athletes           66
Non Athletes       80

Note: Table made from bar graph.

Figure 6
Bar Chart showing Average P duration
in Athletes and Non Athletes

               P duration

Athletes          114
Non Athletes      111

Note: Table made from bar graph.

Figure 7
Bar Chart showing Average PR Intervals
In Athletes and Non Athletes

               PR Intervals

Athletes           146
Non Athletes       139

Note: Table made from bar graph.

Figure 8
Bar Chart showing Average QRS Interval
in Athletes and Non Athletes

                QRS Interval

Athletes             98
Non Athletes         90

Note: Table made from bar graph.

Figure 9
Bar Chart showing Average QT Interval
In Athletes and Non Athletes

               QT Interval in msec

Athletes              401
Non Athletes          351

Note: Table made from bar graph.

Figure 10
Bar Chart showing Average T duration
In Athletes and Non Athletes

               T duration

Athletes          216
Non Athletes      208

Note: Table made from bar graph.

Figure 11
Bar Chart showing Average QTc Bazett's formula
In Athletes and Non Athletes

               QT Calculation in msec

Athletes               420
Non Athletes           400

Note: Table made from bar graph.
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Article Details
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Title Annotation:ORIGINAL ARTICLE; electrocardiogram
Author:Geethanjali, M. Padma; Raju, P.S.N.; Raju, V. Seetharama
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:Jan 12, 2015
Words:6670
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