Red Flags in Family History and Auscultations that may require 12-Lead ECG when Screening Athletes

Annise V. Nalepa, ATC, Dr. Jennifer Blevins-McNaughton, Jamie Cvikel, Ryan Eaton, Dr. Steve J. Simpson, ATC Department of Kinesiology, Tarleton State University

The main components of pre-participation physical exams (PPE) at the NCAA Division II level include a thorough medical history and physical evaluation (American Heart Association (AHA)). “Red flags” for risk on the PPE and medical history include, but are not limited to, heart murmur, diagnosed enlarged heart in a family member, unexplained chest pain, and complaints of "skipped" heartbeats. The purpose of this investigation was to determine if the use of 12-lead ECG for the PPE would reveal further red flags specific to cardiac abnormalities. Twelve-lead electrocardiogram (ECG) was performed on all new athletes at Tarleton State University during the Summer and Fall 2012. Twelve-lead ECGs were reviewed and analyzed by the lab director and attending physician. Upon completion of the PPE, medical history, and ECG, five athletes needed follow-up based on PPE and 12-lead ECG. Reasons for initial concern were the previously stated “red flags” as well as abnormal ECG readings. The abnormal ECG readings included left ventricular hypertrophy (LVH), incomplete right bundle branch block (IRBBB), sinus arrhythmia, and right atrial enlargement (RAE). LVH, IRBB, and sinus arrhythmia were all found to be normal training induced adaptations, however RAE is a non-training induced cardiac abnormality. Of those five, all of them had some type of cardiac adaptation, but one of them presented with RAE. The athlete was an 18-year old male, 64.5” tall, 116 pounds, and in his first year of collegiate cross-country athletics. His HR was 81bpm and blood pressure was 122/72 mmHg. His grandmother was diagnosed with an enlarged heart. The clearing physician, an orthopedic doctor, found only training induced abnormalities in all five athletes. All five athletes were cleared for competition.


Height: 65.5" Weight: 122 lbs



ECG reading
IRBBB LVH T-wave inversion



BP: 118/68 Pulse: 66 bpm Gender: Male

Twin sister has heart murmur

Chest sounds normal


Height: 63"

C/o of skipped heart beats due to a heart murmur diagnosed as a child

Deviated heart


Cleared by Weight: 121 lbs cardiologist in 2010 w/o ECG Currently feels random "skipped heart beats" while running

"Flow murmur"

Early Repolarization


Figure 1. Cardiovascular questions included on PPE

Figure 6. AHA Guidelines (3)

BP: 110/60


Pulse: 72 bpm

C/o random blurred vision Gender: Female

Height: 71" Weight: 148 lbs C BP: 122/72 Pulse: 81 bpm Gender: Male Height: 64.5" Weight: 116 lbs D BP: 118/72 Pulse: 72 bpm Gender: Male Height: 64” Weight: 124 lbs BP: 118/80 Pulse: 54 bpm Gender: Female

2009-2010: Chest pains due to losing fluid Cleared by cardiologist in 2010 w/o ECG

Chest sounds normal



Right Atrial Enlargement Grandmother diagnosed with enlarged heart Chest sounds normal IRBBB Delayed P-wave Progression LVH Yes

IRBBB ECG in HS showed heart murmur Chest sounds normal Sinus arrhythmia Yes


Sudden Cardiac Death (SCD) is a prevalent topic and potential concern for athletes and coaches. Associated with this issue is how to screen for SCD and potentially prevent these adolescent deaths. Some believe the 12-lead ECG is necessary as part of the pre-participation physical exam, whereas others see it as an ineffective screening tool for SCD (1,4). Even though there are critics who are against the implementation of ECGs in PPEs for a variety of reasons, with proper implementation and education, the effectiveness of ECGs can be improved (2). There are a number of reasons that ECGs have not become a requirement for PPEs. Included within these reasons is the high number of athletes who will need follow-up cardiac testing, lack of physician infrastructure, high amount of false-positive readings, and stress on the athlete (1,4,5). False-positives is the main cause of criticism because “most athletes (≥97%) with a positive ECG will have no actual cardiac abnormality”, however the positive ECG can add psychological stress to the athlete since most positive ECG readings include high follow-up costs (4).

Figure 4. Student-athlete PPE results Figure 2. Abnormal ECG guidelines (2)

This case study sought to examine PPEs and their effectiveness. Collegiate athletes encompass a large portion of at risk groups including males, African-Americans, athletes under the age of 20, and endurance athletes (1,4,5). To assist in narrowing down athletes that may be at further risk the AHA recommends a 12point athletic screening (Figure 6). If any one of the 12 recommendations is found in an athlete, then it is protocol to refer the said athlete for cardiovascular evaluation (3). In addition, it must be noted that IRBBB and voltage-only LVH are two common abnormalities that have been accepted as normal adaptations. False-positive rates would be reduced to < 3% (1,2) if all clearing physicians were aware of this. The five athletes from this case study will be followed during their collegiate athletic career to determine if further abnormalities or events occur. As an athletic trainer at the university or high school level, it should be the responsibility of the athletic trainer to provide the best care possible in preventing injuries. Included in this task is educating your physicians on updated PPE screening policies. Whereas the NCAA mandates that 10 of the 12 AHA guidelines are included on PPEs and that a qualified physician evaluates all athletes (3), in the high school level there is no standard for screening athletes. With use of these modern ECG guidelines, false-positive rates have dropped from 7-15% to 2-3% (2) at the NCAA Division I collegiate level. Novel investigations that would screen and follow athletes at the Division II level are needed to improve athlete safety and decrease false positive rates.

The results of this study, as seen in Figure 4, show that one of the five athletes (Athlete D) selected for further screening was identified by the exercise physiologist to have right atrial enlargement (RAE). The abnormal ECG, pictured in Figure 5, shows RAE in Lead II. RAE, as agreed on by the ESC (2) is a nontraining induced abnormality. The attending physician cleared this athlete for cross country. Another unique result was Athlete B. She had many red flags, according to the AHA guidelines (3). However, even though her ECG read with abnormalities, the attending physician cleared this athlete as well. Both athletes completed the season without any problems.

Subjects: Approximately 90 Tarleton State University studentathletes were screened during the Fall and Summer 2012 preparticipation physical exams (PPEs). Five are highlighted in this presentation due to distinguishing presentation features; 3 males (all Cross Country) and 2 females (1 Cross Country, 1 Volleyball), average age was 18 years old. Study Design: All subjects were questioned about past medical history on a medical history questionnaire which included 9 cardiovascular questions (Figure 1). Athletic trainers, an exercise physiologist, and medical doctors reviewed the PPEs for redflags. Five athletes were further evaluated based on abnormal findings. Abnormal findings were based off of the 2010 European Society of Cardiology (ESC) consensus statement for interpretation of 12-lead ECG in athletes as well as from experts familiar with cardiac screening in athletes. (2) (Figure 2)

Figure 3. Characteristics of Fall ECGs

1. Asif IM, Drezner JA. Sudden Cardiac Death and Preparticipation Screening: The Debate Continues – In Support of Electrocardiogram-Inclusive Preparticipation Screening. Progress in Cardiovascular Diseases. 2012; 54: 445-450. doi: 10.1016/j.pcad.2012.01.001 2. Drezner JA, Asif IM, Owens DS, et al. Accuracy of ECG interpretation in competitive athletes: the impact of using standardised ECG criteria. Br J Sports Med. 2012. doi: 10.1136/bjsports-2012-090612 3. Morse E, Funk, M. Preparticipation screening and prevention of sudden cardiac death in athletes: Implications for primary care. Journal of the American Academy of Nurse Practitioners. 2012; 24: 6369. doi: 10.1111/j.1745-7599.2011.00694.x 4. O’Conner DP, Knoblauch MA. Electrocardiogram Testind During Athletic Preparticipations Physical Examinations. Journal of Athletic Training. 2010; 45(3): 265-272. 5. Pelliccia A, Maron BJ, Culasso, F et al. Clinical Significance of Abnormal Electrocardiographic Patterns in Trained Athletes. American Heart Association. 2000; 278-284. Accessed August 29, 2012.

Figure 5. Abnormal ECG of Athlete “D”