The juvenile ECG pattern in adolescent athletes and non-athletes in a national cardiac screening program (BEAT-IT)
Introduction
Anterior T-wave inversion (TWI) is commonly observed in both healthy athletes and non-athletes, with a reported prevalence of 2–7% in Caucasian athletes [[1], [2], [3], [4]] and 12–25% in Afro-Caribbean athletes [1,[5], [6], [7]]. Indeed, it is well established that adolescents frequently exhibit TWI in the anterior leads [8]. This is thought to represent right ventricle electrical predominance as part of a normal physiological phenomenon that commences in infancy [2,[8], [9], [10], [11]]. This so-called juvenile ECG pattern gradually resolves over time, with normalisation of the T waves post-puberty. A juvenile ECG pattern is present in 10–15% of white adolescent athletes aged 12 years old, decreasing to 2.5% at age 14 to 15 years [2,9,12]. Only 0.5% of adolescent athletes older than 16 years exhibit TWI in the anterior leads [8], which favours a more benign course. The latest international criteria for ECG interpretation in athletes do not recommend further evaluation of a juvenile ECG pattern in the absence of symptoms, relevant family history, or other ECG patterns suggestive of cardiac disease [13].
Anterior TWI is however a recognized repolarisation anomaly in cardiomyopathy and is detected in 2–4% of patients with hypertrophic cardiomyopathy [1]. It is also observed in up to 80% of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) [[14], [15], [16], [17], [18]]. Both of these account for a substantial proportion of sudden cardiac death (SCD) in young athletes and non-athletes [19].
Distinguishing benign from pathological TWI has important lifelong implications. This study addressed i) the national prevalence of anterior TWI in adolescents, ii) ST segment and T wave morphology in teens presenting with anterior TWI, iii) the proportion which revert to normal by age 16, and iv) seeks to explore factors which help clinicians predict persistence of important anterior TWI beyond 16 years of age.
Section snippets
Methods
Malta does not support a nationally sponsored cardiac screening program in young asymptomatic individuals in the absence of a relevant family history. Following a collaboration between the Department of Cardiology at Mater Dei Hospital (MDH) and the Ministry of Education, all students attending Form 5 classes (aged circa 15 years) in the 2017/2018 scholastic years were invited to enrol in a national cardiac screening program (BEAT-IT). Screening took place at all schools between September 2017
Baseline characteristics
A cohort of 2672 adolescents aged 14–17 years (mean 15) gave consent for screening. The majority were white Caucasian (95.8%) with 50.4% being male. A third (32.9%) were athletes competing at club or national level. A further 6.9% were recreational athletes. Most athletes (66.0%) exceeded 4 hours/week of physical activity compared to non-athletes (0.2%) (p < 0.0001).
A total of 139 participants (5.2%) exhibited anterior TWI. 5 were excluded because of known congenital heart disease (n = 4) and
Discussion
Anterior TWI is a frequent finding in healthy prepubertal individuals. Unlike individuals with inferior or lateral TWI, the clinical yield in subjects with isolated anterior TWI is low. The international recommendations advise a thorough evaluation in Caucasians with persistent extended anterior TWI beyond V3 at age 16, and beyond V4 in Afrocarribean individuals [13]. Experience however suggests that the sensitivity is also poor when using these criteria, possibly leading to over investigating
Conclusions
This national study is a first of its kind, specifically looking at anterior TWI in a large adolescent population of athletes and non-athletes. T prevalence of anterior TWI is common in prepubertal adolescents (5.0%). Females are more likely to exhibit anterior TWI. Males with anterior TWI are however more likely to manifest profound repolarisation anomalies. These conclusions support the hypothesis that chest wall anatomy in females is a plausible explanation for TWI. This is however a rare
Funding
The project has been supported by the ‘research innovation and development trust’ at the University of Malta as part of a full PhD scholarship in cardiovascular disease.
Authors' contributions
All authors made substantial contributions to the conception/design, acquisition of data, and drafting of the manuscript. The first and last author played an additional role in analysis and interpretation of data. The senior author critically revised the manuscript. All authors have given final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately
Declaration of Competing Interest
The authors report no relationships that could be construed as a conflict of interest.
Acknowledgments
The BEAT-IT investigators would like to thank Dr. Michael Papadakis (St George's, University of London) for his constant support in the evaluation and follow up of study participants. A special thanks also goes to ‘Beating Hearts Malta’ who kindly financially supported RIDT, paving the way for a PhD scholarship (vote number I20LU17) in cardiovascular disease in Malta.
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All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.