Sport- and sex-specific ECG patterns in competitive athletes

Abstract Background A resting 12-lead ECG is essential for monitoring physiological cardiac adaptations in athletes and for identifying early signs of developing pathologies. The prevalence of specific benign findings may be influenced by sex and type of sport. Purpose To describe the prevalence of commonly seen ECG changes: T wave inversion (TWIs), Early repolarisation (ER), Incomplete right bundle branch block (iRBBB), and fragmented QRS (fQRS) across a group of heterogeneous sports, to determine associations between training type and sex with these adaptations. Methods This retrospective study included 307 athletes (age 21.7±5.9; 118 females (38.4%)) representing 8 sports (wrestling (WR)(n=13; age 25.5±9.4), karate (KR) (n=31; age 22.8±4.4), judo (JD) (n=31; age 22.8±4.4), weightlifting (WL) (n=75; age 19±4), gymnastics (GM) (n=64; 18.5±4.8), football (FB) (n=14; age 23.7±3), volleyball (VB) (n=68; age 23.7±5) and rowing (RW)(n=11; 22.1±5) who underwent annual pre-participation cardiovascular screening between 2019 and 2024. Athletes with known cardiovascular disease or with symptoms suggestive of cardiovascular pathology were excluded. Each participant underwent assessment of family history, physical examination, resting ECG, and echocardiography. The sports were categorised according to their physical characteristics, including intensity, dynamic and static components. Rates of each ECG finding were calculated, detailed for each sex and category, and a descriptive analysis was conducted for the overall cohort. Results Anterior TWI in V1–V2 was the most common finding (n=240 (78.2%)), present in all sport disciplines (table 1), nearly all female athletes (89.8%)) and in most male athletes (70.9%)); among the sport disciplines VB had the highest (95.6%) wrestling had the lowest (46.2%) TWI prevalence. ER patterns were found in 43.9% of athletes, with higher prevalence in males and less represented in WL (21.3%) (table 1). iRBBB was a common conduction variant (54%), mostly found in footballers (43%) compared to wrestlers (8%), and was predominant in males (22% of males vs 11% of females). fQRS was defined as an additional spike of QRS complexes without bundle branch block, and was detected in 39% of wrestlers and 29% of footballers, whereas it was infrequent or not found in other sporting disciplines. Conclusion Most of the findings represented the expected "athlete’s heart" changes. The variations in conduction and repolarisation patterns stem from the type of sport and sex. These variations necessitate sport- and sex-specific interpretive criteria to distinguish between physiological and pathological ECG changes in athletes.ECG findings by sport type (%)For image description, please refer to the figure legend and surrounding text. ECG findings by sex (n,%)For image description, please refer to the figure legend and surrounding text.