ECG Features in Athletes vs. ARVC Patients

Study Questions:

What is the prevalence of J point elevation (JPE) and extent of T-wave inversion (TWI) in athletes and arrhythmogenic right ventricular cardiomyopathy (ARVC) patients? Are there novel electrocardiographic (ECG) parameters differentially expressed between athletes and ARVC? Which ECG markers are the strongest independent predictors of ARVC?


The study population was comprised of 100 healthy athletes and 100 ARVC patients 1:1 matched for sex, ethnicity, and age; 97% of the patients were Caucasian. Included subjects had to have TWI ≥1 mm in ≥2 anterior ECG leads without complete right or left bundle branch block. Subjects could not be taking antiarrhythmics at the time of the ECG. All ECGs were analyzed for anterior TWI, inferior TWI, JPE, and ST-segment elevation.


TWI beyond V3, inferior TWI, and premature ventricular contractions (PVCs) were significantly more common in ARVC patients. Left ventricular hypertrophy (LVH) was significantly more prominent in athletes. The combination of TWI >V3 or in inferior leads, PVCs ≥1 on ECG, and Sokolow-Lyon LVH score <20 mm had a sensitivity of 80%, specificity of 82%, and accuracy of 81% for identifying ARVC status. JPE had poor specificity for identifying healthy athletes versus ARVC patients, although the magnitude of JPE, if present, was greater in athletes.


Three ECG markers, namely extensive TWI, presence of any PVCs, and low LVH score, can independently distinguish healthy athletes from ARVC patients.


TWIs on ECG are common in both healthy athletes and ARVC patients. Endurance sport can facilitate ARVC progression as well as physiologic RV remodeling. The overlap can result in challenging ECG interpretation. This study does not address the current consensus recommendation that ST elevation with precordial TWI in black athletes is a normal variant. In addition, infrequent PVCs may not be captured on a single ECG, and LVH will vary with age, sport, and conditioning. However, this important study with a relatively large cohort does suggest that PVCs, low QRS voltage, and TWI beyond V3 on an ECG strongly predict the presence of underlying pathology.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Sports and Exercise Cardiology, Implantable Devices, EP Basic Science, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Arrhythmias, Cardiac, Arrhythmogenic Right Ventricular Dysplasia, Athletes, Bundle-Branch Block, Electrocardiography, Heart Failure, Hypertrophy, Left Ventricular, Primary Prevention, Sports, Ventricular Premature Complexes

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