Sains Malaysiana 50(11)(2021): 3355-3363

http://doi.org/10.17576/jsm-2021-5011-19

Electrocardiographic (ECG) Characteristics among Malaysian Athletes

(Pencirian Elektrokardiografi (ECG) dalam Kalangan Atlet Malaysia)

MOHAMAD SHARIFF A HAMID^1,2*, SAZLINA SHARIFF GHAZALI^3,4, AHMAD MUNAWWAR HELMI SALIM², KAMARUL HASHIMY HUSSEIN², ZULKARNAIN JAAFAR¹ & SAMIHAH ABDUL KARIM¹

¹Sports Medicine Unit, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Federal Territory, Malaysia

²National Sports Institute of Malaysia, Bukit Jalil, 57000 Kuala Lumpur, Federal Territory, Malaysia

³Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor Darul Ehsan, Malaysia

⁴Malaysian Research Institute on Ageing, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor Darul Ehsan, Malaysia

Received: 20 January 2020/Accepted: 7 March 2021

ABSTRACT

The electrocardiogram (ECG) is a graphic representation of the heart's electrical activity. Although it has some limitations as a diagnostic or prognostic tool, it contains a wealth of information necessary for the proper care of a patient with a potential cardiovascular disease. Understanding the ECG changes among athletes would allow medical practitioners to distinguish between normal physiological adaptations and abnormal changes. However, there is limited data on the ECG characteristics among multi-ethnic athletes such as in Malaysia. This study aimed to determine the ECG characteristics and its associated factors among Malaysian national athletes. Malaysian national athletes annual pre-participation medical records were retrieved. Information on sociodemographic, sports and medical history including the 12-lead resting ECG tracings were extracted. ECG were assessed and categorised into normal, physiological adaptation changes, and abnormal ECG using the standardised ‘Seattle criteria’. Differences in ECG characteristics between genders, ethnic background, and type of sports was investigated. Additionally, factors associated with the ECG characteristics were assessed using multiple logistic regression. Majority of Malaysian national athletes had physiological adaptation ECG changes (61%). The most frequent changes were early repolarization, sinus bradycardia and isolated left ventricular hypertrophy. We found significantly higher prevalence of physiological adaptation changes among men (÷²(2,371) = 18.9; p = 0.001) and athletes of Chinese ethnicity (both genders) (÷²(2,356) = 13.8; p = 0.002). Factors associated with physiological ECG changes were men (OR=2.67; 95% CI= 1.68, 4.27; p<0.001) and Chinese ethnicity (OR=2.92; 95% CI=1.68, 4.27; p=0.039). Most athletes had physiological adaptation ECG changes which were significantly associated with male gender and Chinese ethnicity. This information would facilitate the development of a specific guideline in interpreting ECG among Malaysian athletes.

Keywords: Athletes’ heart; electrocardiogram; patterns; physiological adaptation

ABSTRAK

Elektrokardiogram (ECG) adalah gambaran grafik aktiviti elektrik jantung. Walaupun ia mempunyai beberapa batasan sebagai alat diagnostik ataupun prognostik, ia mengandungi pelbagai maklumat yang diperlukan dalam penjagaan pesakit yang berpotensi mengidap penyakit kardiovaskular. Memahami perubahan elektrokardiografi (ECG) dalam kalangan atlet akan membolehkan para pengamal perubatan membezakan antara perubahan akibat penyesuaian fisiologi normal dan perubahan yang tidak normal. Walau bagaimanapun, terdapat data terhad mengenai ciri-ciri ECG dalam kalangan atlet berbilang kaum seperti di Malaysia. Kajian ini bertujuan untuk menentukan ciri-ciri ECG dan faktor yang berkaitan dalam kalangan atlet kebangsaan Malaysia. Rekod perubatan pemeriksaan saringan kesihatan tahunan atlet kebangsaan Malaysia diperoleh untuk penilaian. Maklumat berkaitan sosiodemografi, sukan dan sejarah perubatan termasuk rekod ECG (sewaktu rehat) diekstrak. ECG dinilai dan dikategorikan kepada perubahan adaptasi fisiologi yang normal dan tidak normal ECG menggunakan 'Kriteria Seattle' yang diseragamkan. Perbezaan ciri ECG antara jantina, latar belakang etnik dan jenis sukan diselidiki. Di samping itu, faktor yang dikaitkan dengan ciri-ciri ECG dinilai dengan menggunakan regresi logistik berganda. Majoriti (61%) atlet kebangsaan Malaysia mempunyai perubahan penyesuaian fisiologi ECG terhadap sukan. Perubahan paling kerap ialah pengutuban semula awal, bradikardia sinus dan hipertrofi ventrikel kiri. Perubahan ketara perubahan penyesuaian fisiologi didapati dalam kalangan atlet lelaki (÷²(2,371) = 18.9; p = 0.001) dan atlet etnik Cina (lelaki dan wanita) (÷²(2,356) = 13.8; p = 0.002). Faktor yang dikaitkan dengan perubahan fizikal fisiologi ialah lelaki (OR = 2.67, 95% CI = 1.68, 4.27; p <0.001) dan etnik Cina (OR = 2.92; 95% CI = 1.68, 4.27; p = 0.039). Kebanyakan atlet mempunyai perubahan penyesuaian fisiologi perubahan ECG yang dikaitkan dengan jantina lelaki dan etnik Cina. Maklumat ini akan memudahkan perkembangan garis panduan khusus dalam menafsirkan ECG dalam kalangan atlet Malaysia.

Kata kunci: Corak; elektrokardiogram; jantung atlet; penyesuaian fisiologi

REFERENCES

BMJ Learning. ECG Interpretation in Athletes. https://learning.bmj.com/learning/course-intro/.html?courseId=10042239. Accessed on Jan 20, 2020.

Corîci, O.M., Mirea-Munteanu, O., Donoiu, I., Istrătoaie, O., Corîci, C.A. & Iancău, M. 2018. Gender-related electrocardiographic changes in athletes. Current Health Science Journal 44(1): 29-33. https://doi.org/10.12865/CHSJ.44.01.05.

Corrado, D., Basso, C., Pavei, A., Michieli, P., Schiavon, M. & Thiene, G. 2006. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA 296(13): 1593-1601. https://jamanetwork.com/journals/jama/fullarticle/203513.

D’Silva, A. & Sharma, S. 2014. Exercise, the athlete’s heart, and sudden cardiac death. The Physician and Sports Medicine 42(2): 100-113. https://www.tandfonline.com/doi/abs/10.3810/psm.2014.05.2062.

Department of Statistics Malaysia. 2019. Official Portal. Population Quick Info for 2019 by ethnicity. http://pqi.stats.gov.my/result.php?token=57501aafee1719207693ff96cad1b8cf. Accessed on Jan 20, 2020.

Di Paolo, F.M. & Pelliccia, A. 2007. The “Athlete’s Heart”: Relation to gender and race. Cardiology Clinics 25(3): 383-389. https://doi.org/10.1016/j.ccl.2007.06.010.

Di Paolo, F.M., Schmied, C., Zerguini, Y.A., Junge, A., Quattrini, F., Culasso, F., Dvorak, J. & Pelliccia, A. 2012. The athlete’s heart in adolescent Africans: An electrocardiographic and echocardiographic study. Journal of American College of Cardiology 59(11): 1029-1036. https://doi.org/10.1016/j.jacc.2011.12.008.

Drezner, J.A., Ackerman, M.J., Anderson, J., Ashley, E., Asplund, C.A., Baggish, A.L. Börjesson, M., Cannon, B.C., Corrado, D., DiFiori, J.P., Fischbach, P., Froelicher, V., Harmon, K.G., Heidbuchel, H., Marek, J., Owens, D.S., Paul, S., Pelliccia, A., Prutkin, J.M., Salerno, J.C., Schmied, C.M., Sharma, S., Stein, R., Vetter, V.L. & Wilson, M.G. 2013a. Electrocardiographic interpretation in athletes: The ‘Seattle criteria’. British Journal of Sports Medicine 47(3): 122-124. https://bjsm.bmj.com/content/47/3/122.short.

Drezner, J.A., Fischbach, P., Froelich, V., Marek, J., Pelliccia, A., Prutkin, J.M. Schmied, C.M., Sharma, S., Wilson, M.G., Ackerman, M.J., Anderson, J., Ashley, E., Asplund, C.A., Baggish, A.L., Börjesson, M., Cannon, B.C., Corrado, D., DiFiori, J.P., Harmon, K.G., Heidbuchel, H., Owens, D.S., Paul, S., Salerno, J.C., Stein, R., Vetter, V.L. 2013b. Normal electrocardiographic findings: Recognising physiological adaptations in athletes. British Journal of Sports Medicine 47(3): 125-136. https://bjsm.bmj.com/content/47/3/125.short.

Field, A. 2009. Discovering Statistics Using SPSS. 3rd ed. London: SAGE Publications Ltd.

Finocchiaro, G., Dhutia, H., D’Silva, A., Malhotra, A., Steriotis, A., Millar, L., Prakash, K., Narain, R., Papadakis, M., Sharma, R. & Sharma, S. 2017. Effect of sex and sporting discipline on LV adaptation to exercise. JACC Cardiovascular Imaging 10(9): 966-972. https://www.sciencedirect.com/science/article/pii/S1936878X16307379.

Friedman, H.H. 1985. Diagnostic Electrocardiography and Vectorcardiography. McGraw-Hill Companies. http://books.google.com.my/books?id=_ClsAAAAMAAJ&hl=&source=gbs_api.

Harmon, K.G., Asif, I.M., Klossner, D. & Drezner, J.A. 2011. Incidence of sudden cardiac death in National Collegiate Athletic Association athletes. Circulation 123(15): 1594-1600. https://doi.org/10.1161/CIRCULATIONAHA.110.004622.

Karagjozova, I., Petrovska, S., Nikolic, S., Maleska-Ivanovska, V. & Georgievska-Ismail, L. (2017). Frequency of electrocardiographic changes in trained athletes in the Republic of Macedonia. Open Access Macedonian Journal of Medical Sciences 5(6): 708-713. https://doi.org/10.3889/oamjms.2017.174.

Lim, Z.L., Mokhtar, A.H. & Jaffar, M.R. 2017. Pre-participation evaluation of Malaysian university athletes the importance of cardiovascular screening. Movement Health & Exercise 6(2): 83-96.

Lisman, K.A. 2016. Electrocardiographic evaluation in athletes and use of the Seattle criteria to improve specificity. Methodist DeBakey Cardiovascular Journal 12(2): 81-85. https://doi.org/10.14797/mdcj-12-2-81.

Ma, J.Z., Dai, J., Sun, B., Ji, P., Yang, D. & Zhang, J.N. 2007. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death in China. Journal of Science and Medicine in Sport 10(4): 227-233. https://doi.org/10.1016/j.jsams.2006.07.001.

Magalski, A., Maron, B.J., Main, M.L., McCoy, M., Florez, A., Reid, K.J., Epps, H.W., Bates, J. & Browne, J.E. 2008. Relation of race to electrocardiographic patterns in elite American football players. Journal of American College of Cardiology 51(23): 2250-2255. https://doi.org/10.1016/j.jacc.2008.01.065.

Maron, B.J., Carney, K.P., Lever, H.M., Lewis, J.F., Barac, I., Casey, S.A. & Sherrid, M.V. 2003. Relationship of race to sudden cardiac death in competitive athletes with hypertrophic cardiomyopathy. Journal of American College of Cardiology 41(6): 974-980. https://doi.org/10.1016/s0735-1097(02)02976-5.

Midi, H., Sarkar, S.K. & Rana, S. 2013. Collinearity diagnostics of binary logistic regression model. Journal of Interdisciplinary Mathematics 13(3): 253-267.

Mitchell, J.H., Haskell, W., Snell, P. & Van Camp, S.P. 2005. Task Force 8: Classification of Sports. Journal of American College of Cardiology 45(8): 1364-1367.

Ministry of Health Malaysia. Clinical Practice Guidelines on Management of Obesity 2004.

http://www.moh.gov.my/moh/resources/Penerbitan/CPG/Endocrine/5a.pdf.

Ng, C.T., Chee, T.S., Ling, L.F., Lee, Y.P., Ching, C.K., Chua, T.S.J., Cheok, C. & Ong, H.Y.  2011. Prevalence of hypertrophic cardiomyopathy on an electrocardiogram-based pre-participation screening programme in a young male South-East Asian population: Results from the Singapore Armed Forces Electrocardiogram and Echocardiogram screening protocol. Europace 13(8): 883-888.

Ozo, U. & Sharma, S. 2020. The impact of ethnicity on cardiac adaptation. European Cardiology Review 15: e61. https://doi.org/10.15420/ecr.2020.01.

Papadakis, M., Wilson, M.G., Ghani, S., Kervio, G., Carre, F. & Sharma, S. 2012. Impact of ethnicity upon cardiovascular adaptation in competitive athletes: Relevance to preparticipation screening. British Journal of Sports Medicine 46(Suppl. 1): i22-i28. https://doi.org/10.1136/bjsports-2012-091127.

Pelliccia, A., Culasso, F., Di Paolo, F.M., Accettura, D., Cantore, R., Castagna, W., Ciacciarelli, A., Costini, G., Cuffari, B., Drago, E., Federici, V., Gribaudo, C.G., Lacovelli, G., Landolfi, L., Menichetti, G., Atzeni, U.O., Parisi, A., Pizzi, A.R., Rosa, M., Santelli, F., Santilio, F., Vagnini, A., Casasco, M. & Di Luigi, L. 2007. Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. European Heart Journal 28(16): 2006-2010. https://academic.oup.com/eurheartj/article/28/16/2006/493352.

Perrin, T., Trachsel, L.D., Schneiter, S., Menafoglio, A., Albrecht, S., Pirrello, T., Eser, P., Roten, L., Gojanovic, B. & Wilhelm, M. 2017. Prevalence of abnormal electrocardiograms in Swiss elite athletes detected with modern screening criteria. Swiss Medical Weekly 146: w14376. https://boris.unibe.ch/id/eprint/110459.

Rawlins, J., Carre, F., Papdakis, M., Edwards, C.P., Chandra, N. & Sharma, S. 2009. Ethnic differences in physiological cardiac adaptation to intense physical exercise in highly trained female athletes. Circulation 121(9): 1078-1085. https://heart.bmj.com/content/95/Suppl_1/120.abstract.

Riding, N.R., Sharma, S., McClean, G., Adamuz, C., Watt, V. & Wilson, M.G. 2019. Impact of geographical origin upon the electrical and structural manifestations of the black athlete’s heart. European Heart Journal 40(1): 50-58.

Sia, C., Dalakoti, M., Tan, B.Y.Q., Lee, E.C.Y., Shen, X., Wang, K., Lee, J.S., Arulanandam, S., Chow, W., Yeo, T.J., Yeo, K.K., Chua, T.S.J., Tan, R.S., Lam, C.S.P. & Chong, D.T.T. 2019. A Population‐wide study of electrocardiographic (ECG) norms and the effect of demographic and anthropometric factors on selected ECG characteristics in young, Southeast Asian males - results from the Singapore Armed Forces ECG (SAFE) study. Annals of Noninvasive Electrocardiology 24(3): e12634. https://onlinelibrary.wiley.com/doi/pdf/10.1111/anec.12634.

Sokolow, M. & Lyon, T.P. 1949. The ventricular complex in left ventricular hypertrophy as obtained by unipolar precordial and limb leads. American Heart Journal 37(2): 161-186. https://www.sciencedirect.com/science/article/pii/0002870349905621.

Waase, M.P., Mutharasan, R.K., Whang, W., DiTullio, M.R., DiFiori, J.P., Callahan, L., Mancell, J., Phelan, D., Schwartz, A., Homma, S. & Engel, D.J. 2018. Electrocardiographic findings in National Basketball Association athletes. JAMA Cardiology 3(1): 69-74.

*Corresponding author; email: ayip@um.edu.my