Prevalence of Cardiomyopathy in Italian Asymptomatic Children With Electrocardiographic T-Wave Inversion at Preparticipation Screening

Background— T-wave inversion on a 12-lead ECG is usually dismissed in young people as normal persistence of the juvenile pattern of repolarization. However, T-wave inversion is a common ECG abnormality of cardiomyopathies such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy, which are leading causes of sudden cardiac death in athletes. We prospectively assessed the prevalence, age relation, and underlying cardiomyopathy of T-wave inversion in children undergoing preparticipation screening. Methods and Results— The study population included 2765 consecutive Italian children (1914 male participants; mean age, 13.9±2.2 years; range 8–18 years) undergoing preparticipation screening including an ECG. Of 229 children (8%) who underwent further evaluation because of positive findings at initial preparticipation screening, 33 (1.2%) were diagnosed with cardiovascular disease. T-wave inversion was recorded in 158 children (5.7%) and was localized in the right precordial leads in 131 (4.7%). The prevalence of right precordial T-wave inversion decreased significantly with increasing age (8.4% in children <14 years of age versus 1.7% in those ≥14 years; P<0.001), pubertal development (9.5% of children with incomplete versus 1.6% with complete development; P<0.001), and body mass index below the 10th percentile (P<0.001). Incomplete pubertal development was the only independent predictor for right precordial T-wave inversion (odds ratio, 3.6; 95% confidence interval, 1.9–6.8; P<0.001). Of 158 children with T-wave inversion, 4 (2.5%) had a diagnosis of cardiomyopathy, including arrhythmogenic right ventricular cardiomyopathy (n=3) and hypertrophic cardiomyopathy (n=1). Conclusions— The prevalence of T-wave inversion decreases significantly after puberty. Echocardiographic investigation of children with postpubertal persistence of T-wave inversion at preparticipation screening is warranted because it may lead to presymptomatic diagnosis of a cardiomyopathy that could lead to sudden cardiac death during sports.

[1]  Y. Oade,et al.  Arrhythmogenic right ventricular cardiomyopathy , 2011, BMJ Case Reports.

[2]  G. Kervio,et al.  The prevalence, distribution, and clinical outcomes of electrocardiographic repolarization patterns in male athletes of African/Afro-Caribbean origin. , 2011, European heart journal.

[3]  Wojciech Zareba,et al.  Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia: Proposed Modification of the Task Force Criteria , 2010, European heart journal.

[4]  G. Kervio,et al.  Ethnic Differences in Physiological Cardiac Adaptation to Intense Physical Exercise in Highly Trained Female Athletes , 2010, Circulation.

[5]  Barry J Maron,et al.  Recommendations for interpretation of 12-lead electrocardiogram in the athlete. , 2009, European heart journal.

[6]  S. Firoozi,et al.  Prevalence and significance of T-wave inversions in predominantly Caucasian adolescent athletes. , 2009, European heart journal.

[7]  G. Whyte,et al.  Ethnic differences in left ventricular remodeling in highly-trained athletes relevance to differentiating physiologic left ventricular hypertrophy from hypertrophic cardiomyopathy. , 2008, Journal of the American College of Cardiology.

[8]  B. Maron,et al.  Outcomes in athletes with marked ECG repolarization abnormalities. , 2008, The New England journal of medicine.

[9]  D. Corrado,et al.  Appropriate interpretation of the athlete's electrocardiogram saves lives as well as money. , 2007, European heart journal.

[10]  A. Pelliccia,et al.  Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. , 2007, European heart journal.

[11]  Maurizio Schiavon,et al.  Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. , 2006, JAMA.

[12]  E. Spada,et al.  Italian cross-sectional growth charts for height, weight and BMI (2 to 20 yr) , 2006, Journal of endocrinological investigation.

[13]  Barry J Maron,et al.  Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interd , 2006, Circulation.

[14]  D. Corrado,et al.  Essay: Sudden death in young athletes , 2005, The Lancet.

[15]  F. Marcus.  Prevalence of T-wave inversion beyond V1 in young normal individuals and usefulness for the diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia. , 2005, The American journal of cardiology.

[16]  B. Maron,et al.  Introduction: eligibility recommendations for competitive athletes with cardiovascular abnormalities-general considerations. , 2005, Journal of the American College of Cardiology.

[17]  C. Wren,et al.  Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. , 2005, European heart journal.

[18]  H. Calkins,et al.  Electrocardiographic Features of Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy According to Disease Severity: A Need to Broaden Diagnostic Criteria , 2004, Circulation.

[19]  Barry J Maron,et al.  American College of Cardiology/European Society of Cardiology clinical expert consensus document on hypertrophic cardiomyopathy. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice G , 2003, Journal of the American College of Cardiology.

[20]  John B Carlin,et al.  The epidemiology of childhood cardiomyopathy in Australia. , 2003, The New England journal of medicine.

[21]  E John Orav,et al.  The incidence of pediatric cardiomyopathy in two regions of the United States. , 2003, The New England journal of medicine.

[22]  B. Maron.  Hypertrophic cardiomyopathy: a systematic review. , 2002, JAMA.

[23]  D. Corrado,et al.  Sudden cardiac death in young people with apparently normal heart. , 2001, Cardiovascular research.

[24]  B. Maron,et al.  Clinical significance of abnormal electrocardiographic patterns in trained athletes. , 2000, Circulation.

[25]  P. Elliott,et al.  Electrocardiographic changes in 1000 highly trained junior elite athletes. , 1999, British journal of sports medicine.

[26]  Asso,et al.  Screening for hypertrophic cardiomyopathy in young athletes. , 1998, The New England journal of medicine.

[27]  P. Thompson,et al.  The athlete's heart. , 1997, Clinics in sports medicine.

[28]  P. Nihoyannopoulos,et al.  The standard electrocardiogram as a screening test for hypertrophic cardiomyopathy. , 1995, The American journal of cardiology.

[29]  G. Thiene,et al.  Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy. Task Force of the Working Group Myocardial and Pericardial Disease of the European Society of Cardiology and of the Scientific Council on Cardiomyopathies of the International Society and Federation of Cardiology. , 1994, British heart journal.

[30]  A. Ward,et al.  Athletic heart syndrome. , 1992, Clinics in sports medicine.

[31]  N. Schiller,et al.  Two-dimensional echocardiographic determination of left ventricular volume, systolic function, and mass. Summary and discussion of the 1989 recommendations of the American Society of Echocardiography. , 1991, Circulation.

[32]  M. Proschan,et al.  The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes. , 1991, The New England journal of medicine.

[33]  D. Corrado,et al.  Sudden death in young competitive athletes: clinicopathologic correlations in 22 cases. , 1990, The American journal of medicine.

[34]  B. Maron,et al.  Development and progression of left ventricular hypertrophy in children with hypertrophic cardiomyopathy. , 1986, The New England journal of medicine.

[35]  Daniel E. Guyer,et al.  Echocardiographic measurement of right ventricular volume. , 1984, Circulation.

[36]  François Soumis,et al.  Normal ECG standards for infants and children , 1980, Pediatric Cardiology.

[37]  J M Tanner,et al.  Variations in the Pattern of Pubertal Changes in Boys , 1970, Archives of disease in childhood.

[38]  J M Tanner,et al.  Variations in pattern of pubertal changes in girls. , 1969, Archives of disease in childhood.

[39]  R. Hiss,et al.  Electrocardiographic findings in 67,375 asymptomatic subjects. VIII. Nonspecific T wave changes. , 1960, The American journal of cardiology.

[40]  J. Thomas,et al.  Observations on the T wave and S-T segment changes in the precordial electro-cardiogram of 320 young Negro adults. , 1960, The American journal of cardiology.

[41]  C. W. Gottschalk,et al.  A Comparison of the Precordial S- T and T Waves in the Electrocardiograms of 600 Healthy Young Negro and White Adults , 1956, Southern medical journal.

[42]  Z. Piotrowski,et al.  [Normal electrocardiogram in childhood]. , 1954, Pediatria polska.

[43]  R. F. Ziegler.  Characteristics of the Unipolar Precordial Electrocardiogram in Normal Infants , 1951, Circulation.

[44]  R. Suárez.  The T-wave of the precordial electrocardiogram at different age levels. , 1946, American heart journal.

[45]  E. Lepeschkin.  Über das normale Brustwand-Elektrokardiogramm im Kindesalter , 1938, Archiv für Kreislaufforschung.

[46]  A. Moss,et al.  Contemporary Definitions and Classification of the Cardiomyopathies , 2006 .

[47]  E. Prescott.  Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. , 2006, European heart journal.

[48]  It Istituto Superiore di Sanit,et al.  Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and , 2005 .

[49]  N. Wolfe.  Electrocardiographic features of arrhythmogenic right ventricular dysplasia/cardiomyopathy according to disease severity: A need to broaden diagnostic criteria , 2005 .

[50]  H. Bjørnstad,et al.  Electrocardiographic findings of repolarization in athletic students and control subjects. , 1994, Cardiology.