Low voltage with high suspicion in athlete’s heart: Authors’ reply

We thank Adeba et al.1 for their interest in our study. Based on their experience with two athletes with low QRS voltages (LQRSVs), complex ventricular arrhythmias, and underlying non-ischaemic left ventricular scars (NILVSs), the authors of the letter to the editor raised two important questions: (i) should we perform cardiac magnetic resonance (CMR) to all athletes with LQRSV regardless of associated clinical abnormalities and (ii) can NILVS be the result of exercise-induced cardiac damage? We still do not have an answer to the second question and we agree that more data need to be collected. However, we would like to address the first point. The background of our study2 was that the 2017 International recommendations for interpretation of the athlete’s electrocardiogram (ECG) did not mention LQRSV,3 although this sign can be associated with potentially at-risk myocardial substrates (particularly the NILVs).4 The primary study result was that LQRSVs are uncommon in healthy athletes at difference to patients with cardiomyopathies; the secondary was that in a proportion of athletes, LQRSV were associated with pathological myocardial substrates on CMR. These findings lead to classify this previously unaddressed ECG pattern among the uncommon ECG abnormalities requiring further tests. The problem is what tests.