Early Repolarization Pattern in Competitive Athletes

Abstract

Background Inferior lead early repolarization pattern (ERP) has recently been associated with sudden cardiac death. Although ERP is common among athletes, prevalence, ECG lead distribution, clinical characteristics, and effects of physical training remain uncertain. We sought to examine the non-anterior early repolarization pattern (ERP) in competitive athletes. Methods and Results ERP was assessed in a cross-sectional cohort of collegiate athletes (n=879). The relationship between ERP and cardiac structure were then examined in a longitudinal subgroup (n=146) before and after a 90-day period of exercise training. ERP was defined as J-point elevation ≥ 0.1 mV in at least two leads within a non-anterior territory (inferior [II, III, aVF] or lateral [I, aVL, V4-V6]). Non-anterior ERP was present in 25.1% (221/879) of athletes including the inferior subtype in 3.8% (33/879). Exercise training led to significant increases in the prevalence of ERP and the inferior subtype but there were no associations between ERP and echocardiographic measures of left ventricular remodeling. In a multivariable model, ERP was associated with black race (OR 5.84, CI 3.54-9.61, p<0.001), increased QRS voltage (OR 2.08, CI 1.71-2.52, p<0.001), and slower HR (OR 1.54, CI 1.26-1.87, p<0.001). Conclusions Non-anterior ERP including the inferior subtype are common and have strong clinical associations among competitive athletes. The finding of increased ERP prevalence following intense physical training establishes a strong association between exercise and the ERP.

Cardiovascular adaptation in athletes

“…Athletes exhibit an increased incidence of early repolarization pattern on 12 lead ECG, a pattern that can evolve with intense training and dissipate with detraining. 33 The mechanism is uncertain, but is postulated to be due to parasympathetic modulation of ventricular repolarization, increasing regional dispersion of repolarization of the ventricular myocardium 37 . This may be a direct effect of the vagus nerve in the ventricle, but could also be due to heightened vagal effects on sympathetic nervous activity -termed "accentuated antagonism" and first described at the cellular level by Bailey and Watanabe.…”

Common electrocardiogram variations pre‐ and post‐marathon

“…Typically manifesting with ST elevation, J‐point elevation or terminal slurring of the QRS; ERP is generally thought to be a benign process unreflective of an underlying structural abnormality and commonly observed in healthy athletes (Fig. 1) 4. Ten participants with ERP had the phenomenon present to the same degree pre‐ and postrace.…”

“…Early repolarization pattern deserves specific mention because it has been associated with an increased risk of ventricular fibrillation and sudden cardiac death 4, 13, 14. However, in otherwise, healthy athletes without heart disease the strong association between athletic performance and ERP appears benign 4.…”

“…However, in otherwise, healthy athletes without heart disease the strong association between athletic performance and ERP appears benign 4. Typically, ERP will cooccur with other manifestations of the athlete's heart , including isolated voltage criteria for LVH 13.…”

Clinical, Electrocardiographic, Echocardiographic Characteristics and Long-Term Follow-Up of Elite Soccer Players With J-Point Elevation

“…2,3,7,8 For this reason, the classical ER pattern found in athletes, by inference from the general population 2 and from short-term follow-up studies, 9 is considered benign. In contrast, evidence of an increased risk for sudden death exists for ER patterns characterized by J-point elevation associated with a horizontal/descending ST segment.…”