Outcomes in Athletes with Marked ECG Repolarization Abnormalities

Antonio Pelliccia, M.D., Fernando M. Di Paolo, M.D., Filippo M. Quattrini, M.D., Cristina Basso, M.D., Franco Culasso, Ph.D., Gloria Popoli, M.D., Rosanna De Luca, M.D., Antonio Spataro, M.D., Alessandro Biffi, M.D., Gaetano Thiene, M.D., and Barry J. Maron, M.D.
Background Young, trained athletes may have abnormal 12-lead electrocardiograms (ECGs) without evidence of structural cardiac disease. Whether such ECG patterns represent the initial expression of underlying cardiac disease with potential long-term adverse consequences remains unresolved. We assessed long-term clinical outcomes in athletes with ECGs characterized by marked repolarization abnormalities.
Methods From a database of 12,550 trained athletes, we identified 81 with diffusely distributed and deeply inverted T waves (2 mm in at least three leads) who had no apparent cardiac disease and who had undergone serial clinical, ECG, and echocardiographic studies for a mean (±SD) of 9±7 years (range, 1 to 27). Comparisons were made with 229 matched control athletes with normal ECGs from the same database.
Results Of the 81 athletes with abnormal ECGs, 5 (6%) ultimately proved to have cardiomyopathies, including one who died suddenly at the age of 24 years from clinically undetected arrhythmogenic right ventricular cardiomyopathy. Of the 80 surviving athletes, clinical and phenotypic features of hypertrophic cardiomyopathy developed in 3 after 12±5 years (at the ages of 27, 32, and 50 years), including 1 who had an aborted cardiac arrest. The fifth athlete demonstrated dilated cardiomyopathy after 9 years of follow-up. In contrast, none of the 229 athletes with normal ECGs had a cardiac event or received a diagnosis of cardiomyopathy 9±3 years after initial evaluation (P=0.001).
Conclusions Markedly abnormal ECGs in young and apparently healthy athletes may represent the initial expression of underlying cardiomyopathies that may not be evident until many years later and that may ultimately be associated with adverse outcomes. Athletes with such ECG patterns merit continued clinical surveillance.