Elsevier

International Journal of Cardiology

Volume 371, 15 January 2023, Pages 508-515
International Journal of Cardiology

The juvenile ECG pattern in adolescent athletes and non-athletes in a national cardiac screening program (BEAT-IT)

https://doi.org/10.1016/j.ijcard.2022.09.005Get rights and content

Highlights

  • Anterior T wave inversion (ATWI) is a frequent finding in healthy adolescents.

  • Prevalence of isolated ATWI was 5.0%, commoner in females (6.3% vs 3.7%).

  • Extended ATWI were more common in female athletes (4.2%) vs non-athletes (2.1%).

  • Females often had shallow TWI without overt ST segment abnormalities.

  • Deep TWI and ST segment changes were more frequent in males.

  • 0.2% of cases with ATWI persisted at ≥16 year (an unpredictable phenomenon).

Abstract

Background

Anterior T wave inversion (TWI) is frequent in healthy adolescent individuals (juvenile ECG pattern), normalising after puberty. Its clinical implications are uncertain.

Aim

This study assessed a) national prevalence of anterior TWI, b) ST segment morphology, c) proportion of individuals with a juvenile ECG pattern whose ECG normalises and d) factors predicting TWI persistence >16 years.

Methods

Adolescents (mean 15y) in Malta were systematically invited to enrol in a cardiac screening program. Subjects completed a health questionnaire and an ECG at their school. Participants with TWI were labelled as TWI in V1-V2 or extended TWI (V1-V3/4). The latter were followed at 1 year with a repeat ECG. Those with persistent extended anterior TWI were offered evaluation and surveillance.

Results

The prevalence of isolated anterior TWI was 5.0%, commoner in females (6.3%) independent of athletic ability. Extended TWI was commoner in female athletes (4.2%, non-athletes 2.1%). Females often had shallow TWI without overt ST segment abnormalities. Deep TWI and ST segment changes were more frequent in males. Only 0.2% of cases persisted ≥16 years of age. ST segment characteristics were not able to predict T wave normalisation. No events took place during follow up (40 ± 9 months).

Conclusion

Anterior TWI is a frequent phenomenon in adolescents, especially in females. Female athletes are also more likely to have extended anterior TWI. Only 0.2% of cases have persistent anterior TWI at 16 years of age. Chest wall anatomy may explain this phenomenon in females. It is uncommon in males, hence why surveillance is more prudent.

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.

References (33)

  • V. van Le et al.

    Addition of the Electrocardiogram to the Preparticipation Examination of College Athletes

    (2010)
  • A. Zorzi et al.

    Electrocardiographic predictors of electroanatomic scar size in arrhythmogenic right ventricular cardiomyopathy: implications for arrhythmic risk stratification

    J. Cardiovasc. Electrophysiol.

    (2013)
  • A. Pelliccia et al.

    Outcomes in athletes with marked ECG repolarization abnormalities

    N. Engl. J. Med.

    (2008)
  • J. Basu et al.

    Prevalence and progression of the juvenile pattern in the electrocardiogram of adolescents

    Heart.

    (2018)
  • M. Papadakis et al.

    Prevalence and significance of T-wave inversions in predominantly Caucasian adolescent athletes

    Eur. Heart J.

    (2009)
  • S. Sharma et al.

    Electrocardiographic changes in 1000 highly trained junior elite athletes

    Br. J. Sports Med.

    (2008)
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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.

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