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CASE REPORT
Year : 2018  |  Volume : 18  |  Issue : 1  |  Page : 52-54

Diagnostic dilemma of deep T-wave inversion for sports participation: Two contrasting case reports


1 Department of Sports Medicine, NSNIS, Patiala, Punjab, India
2 Department of Cardiology, Amar Hospital, Patiala, Punjab, India

Date of Web Publication15-Feb-2018

Correspondence Address:
Jeewan Kumar
Department of Sports Medicine, NSNIS, Patiala - 147 001, Punjab
India
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DOI: 10.4103/sjsm.sjsm_38_17

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  Abstract 


Sudden cardiac death (SCD) is the leading cause of death in athletes. Among which, cardiomyopathy is the most common in young asymptomatic sportsperson. The electrocardiogram (ECG) is used as a primary screening and diagnostic tool for detecting underlying conditions associated with SCD. However, providing medical clearance for an asymptomatic athlete without any positive personal or family history is especially challenging when the athlete demonstrates abnormal ECG, particularly repolarization patterns, highly suggestive of an inherited cardiomyopathy, or ion channelopathy. This paper presents two such cases of contrasting diagnostic conundrum which may help sports physicians and cardiologists working with athletes.

  Abstract in Arabic 

الموت القلبي المفاجئ هو السبب الرئيسي للوفاة في الرياضيين. ومن بين الاسباب بل لأكثر شيوعا في الشباب الرياضيين الذين ليس لديهم أعراض اعتلال عضلة القلب. يتم استخدام تخطيط القلب الكهربائي كأداة الفحص الأولي والتشخيص للكشف عن الظروف الأساسية المرتبطة بالموت القلبي المفاجئ ومع ذلك، توفير التخليص الطبي للرياضي بدون أعراض من دون أي تاريخ شخصي أو تاريخ عائلي إيجابي بشكل خاص عندما يظهر الرياضي تخطيط القلب غير طبيعي، وخاصة أنماط الاستقطاب يكون مؤشرا الى اعتلال عضلة القلب الموروثة، أو اعتلال قناة الأيونات. تقدم هذه الورقة حالتين من هذا النوع فيهما معضلة التشخيص المتناقضة، والتي قد تساعد الأطباء والرياضيين وأطباء القلب العاملين مع الرياضيين

Keywords: Athletes, electrocardiogram, preparticipation screening, T-wave inversion


How to cite this article:
Mallick A, Dande J, Kumar J. Diagnostic dilemma of deep T-wave inversion for sports participation: Two contrasting case reports. Saudi J Sports Med 2018;18:52-4

How to cite this URL:
Mallick A, Dande J, Kumar J. Diagnostic dilemma of deep T-wave inversion for sports participation: Two contrasting case reports. Saudi J Sports Med [serial online] 2018 [cited 2018 Sep 22];18:52-4. Available from: http://www.sjosm.org/text.asp?2018/18/1/52/225294




  Introduction Top


Cardiovascular-related sudden death is the leading cause of mortality in athletes during sport.[1] The majority of disorders associated with increased risk of sudden cardiac death (SCD), includes cardiomyopathies and primary electrical diseases, which are having distinct abnormal findings on a 12-lead electrocardiogram (ECG). Some recent case studies [2] demonstrated the complex scenarios faced regularly by clinicians in providing medical clearance for the competitive athletes. The quantification of the risk of SCD for an athlete with T-wave inversion but without any positive history, and the secondary investigation is still unclear. Although both the ACC 36th Bethesda Conference and European Society of Cardiology guidelines recommend to withdraw an athlete with sign of “probable” cardiomyopathy from competitive sport and high-intensity training,[3] these guidelines may differ in the management outcome with regard to sporting clearance.

In National Institute of Sports, Patiala, all the elite athletes are subjected to preparticipation medical screening in the department of sports medicine and on medical clearance, only they are included in the national camps. This includes detailed personal and family history, cardiovascular examination, and a resting 12 leads ECG. All the ECGs are interpreted using “Seattle criteria,” developed in 2012 by group of experts of the American Medical Society for Sports Medicine cosponsored by the FIFA Medical Assessment and Research Center.[4]


  Case Reports Top


Case 1

A 30-year-old male international boxer was screened during the routine preparticipation medical examination. For the past 6 years, he was training 4 h/day 5 days a week. He did not report any cardiac symptoms, denying any chest pain, palpitations, or syncope either at rest or during exercise. Family history was also negative for any acquired cardiovascular disease, diabetes, or hypertension. He did not report any sudden death in the family either. Physical examination was unremarkable (height-171 cm, weight-68 kg, and blood pressure-126/82 mmHg). A resting 12 lead ECG showed T-wave inversion in lead III, aVR, V1 to V6 [Figure 1].
Figure 1: T-wave inversion in lead III, aVR, V1 to V6

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Due to this abnormal ECG pattern, echocardiography was performed which revealed concentric left ventricular hypertrophy (LVH) having end-systolic (ES) posterior wall thickness 1.8 cm and interventricular septal thickness 1.6 cm with normal left ventricular cavity dimension (ES-3 cm, end diastolic-4.8 cm) and function. Transesophageal echocardiography also revealed the same. Having this abnormal ECG and suspected echocardiography, the athlete was referred for cardiac magnetic resonance (CMR) which also revealed cardiomegaly with the enlarged right atrium and right ventricle (RV). No regional wall motion abnormality is seen in either of the ventricles at rest. No focal or diffuse myocardial bulge is seen in RV. No fat signals are seen in right/left ventricles. There was no abnormal subendocardial enhancement seen in either of the ventricles even on delayed myocardial scan. There was also no evidence of pericardial effusion. The mediastinal vessels show normal relationship and morphology. Overall, there was no evidence of the “classic” features of dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy (ARVC), or hypertrophic cardiomyopathy (HCM).

In summary, the player was having an abnormal ECG without any positive personal or family history. The overall investigations could not confirm any diagnosis of cardiomyopathy. Thus, the athlete was provided medical clearance but was advised to undergo complete cardiological evaluation annually along with one of the family members (>10 years) including echocardiography, and educated to seek immediate medical attention if he becomes symptomatic.

Case 2

A 27-year-old male discus thrower was evaluated during the routine preparticipation medical examination. For the past 8 years, he was training 4–5 h/day 5 days a week. He did not have any cardiac symptoms, also denying any chest pain, palpitations, or syncope either at rest or during exercise. There was no history of frequent upper respiratory infections but complained of occasional headache. There was no significant family history for any congenital or acquired cardiovascular disease, diabetes, or hypertension. He also did not report any sudden death in the family either.

His physical parameters include (height-189 cm, weight-104 kg), however, blood pressure was on the higher side-140/90 mmHg (Stage 1 hypertension). A resting 12-lead ECG was done as routine procedure which showed gross sign of LVH as per Sokolow–Lyon criteria and deep T-wave inversion in lead II, aVL, aVF, V4 to V6. Hence, he was advised echocardiography which revealed ES left ventricular posterior wall thickness 2 cm and interventricular septal thickness 2.5 cm. The end diastolic left ventricular diameter was 5.1 cm with grade III diastolic dysfunction. The finding was consistent with the typical feature of HCM. There was also no significant valvular pathology as such [Figure 2].
Figure 2: T-wave inversion in lead II, aVL, aVF, V4 to V6

Click here to view


Based on the abnormal findings, the patient was referred to cardiologist for further investigation and management and declared unfit for high-intensity training and competitive sports provisionally. However, he refused to undergo any further investigations and left the national camp.


  Discussion Top


Deep T-wave inversions in the lateral leads are of major concern because these ECG alterations are recognized manifestation of HCM and ARVC. Inverted T-waves may represent the only sign of an inherited heart muscle disease even in the absence of any other features and before structural changes in the heart can be detected. However, recent studies examining cardiac adaptation in African/Afro-Caribbean male athletes have demonstrated that these athletes present with more striking repolarization changes than caucasians of similar age and size participating in identical sports. The two cases presented here demonstrated completely different scenario. Both the athletes were having distinctly abnormal repolarization pattern, but the first case did not prove to be associated with any pathology even after all the relevant investigations, hence declared fit, whereas the second athlete was having typical pattern of HCM in echocardiography. It would have been interesting to see the CMR report to identify the pattern of wall abnormality. Recently, Pelliccia et al.[5] reported on 81 athletes (from a database of 12,550) with diffusely distributed and deeply inverted T-waves, with no apparent cardiac disease, who had undergone serial ECG and echocardiographic studies for 9 ± 7 years (range, 1–27 years).

In line with these findings, it has been recommended that the first player should undergo an annual review, with genetic counseling for the future mutation analysis. Furthermore, confirmed genotype positivity for a cardiomyopathy may change the medical clearance recommendations for physical activity, whereas the second athlete needs to be under supervision of a cardiologist for further investigations and management.

The uncertainty surrounding the cause of the first player's repolarization abnormalities poses a serious challenge for physician but did not warrant disqualification from competitive sport. However, the importance of continued clinical surveillance and follow-up of athletes even in the absence of cardiac symptoms and/or clinically demonstrable heart disease should be highlighted. Unfortunately, the risk of SCD for this player cannot be quantified because the precise significance of such repolarization changes remains unresolved.


  Conclusion Top


It is well known that a small number of athletes will represent with unusual repolarization pattern suggestive of cardiomyopathy or ion channelopathy. Moreover, T-wave inversion also depends on age, sex, and ethnicity. T-wave inversion in anterior leads may be a physiological finding in African/Afro-Caribbean athletes, whereas same in lateral leads should always be reviewed with suspicion. Further research should include mutation analysis to identify athletes at risk. T-wave inversion should be identified as an early finding of an inherited cardiovascular disorder, and these athletes should be kept under clinical follow-up. Whether performed for screening or diagnostic purposes, it is important that sports physicians and cardiologists should be guided by ECG interpretation standards that improve underlying disease detection and reduce false-positive results but at the same time prevent the catastrophic event of SCD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of sudden cardiac death in National Collegiate Athletic Association athletes. Circulation 2011;123:1594-600.  Back to cited text no. 1
[PUBMED]    
2.
Wilson MG, Chatard JC, Hamilton B, Prasad SK, Carré F, Whyte GP, et al. Significance of deep T-wave inversions in an asymptomatic athlete with a family history of sudden death. Clin J Sport Med 2011;21:138-40.  Back to cited text no. 2
    
3.
Pelliccia A, Fagard R, Bjørnstad HH, Anastassakis A, Arbustini E, Assanelli D, et al. Recommendations for competitive sports participation in athletes with cardiovascular disease: A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2005;26:1422-45.  Back to cited text no. 3
    
4.
Drezner JA, Ackerman MJ, Anderson J, Ashley E, Asplund CA, Baggish AL, et al. Electrocardiographic interpretation in athletes: The 'Seattle criteria'. Br J Sports Med 2013;47:122-4.  Back to cited text no. 4
    
5.
Pelliccia A, Di Paolo FM, Quattrini FM, Basso C, Culasso F, Popoli G, et al. Outcomes in athletes with marked ECG repolarization abnormalities. N Engl J Med 2008;358:152-61.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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