Elsevier

Heart Rhythm

Volume 12, Issue 1, January 2015, Pages 78-85
Heart Rhythm

Clinical significance of exercise-induced ventricular tachyarrhythmias in trained athletes without cardiovascular abnormalities

https://doi.org/10.1016/j.hrthm.2014.09.009Get rights and content

Background

Exercise-induced ventricular tachyarrhythmias raise clinical concern as a marker of increased risk in the presence of underlying cardiovascular disease.

Objective

The aim of this study was to clarify the clinical significance of exercise-induced ventricular tachyarrhythmias in competitive athletes without evident cardiac abnormalities.

Methods

Exercise electrocardiographic testing was performed in 5011 consecutive athletes without heart disease and analyzed for the occurrence of ventricular arrhythmias.

Results

Of the 5011 athletes, 367 (7.3%) showed ≥1 premature ventricular beat (PVB), including 331 (6.6%) with ≤10 PVBs and 36 (0.7%) with >10 PVBs and/or ≥1 ventricular couplets, and/or ≥1 bursts of nonsustained ventricular tachycardia. The 331 athletes with ≤10 PVBs had no restriction from competitive sports, and repeated exercise testing over 3–12 months showed spontaneous reduction of arrhythmia (from 5.2 ± 4 to 4 ± 6 PVBs; P = .002), including 83 of 331 (23%) with disappearance of PVBs. The remaining 36 athletes were disqualified from sports because of frequent and/or complex arrhythmias; 23 showed reduction of arrhythmia at 3–12 months (from 46 ± 42 to 28 ± 11 PVBs, from 8 ± 10 to 3 ± 3 couplets, and from 3.6 ± 6 to 1 ± 1 nonsustained ventricular tachycardia; P = .05) and were readmitted to competition. The other 13 athletes with persistent arrhythmias were considered for radiofrequency ablation, of whom 6 were successfully treated with abolition of arrhythmias and permitted to return to competitive sports. No events or cardiovascular disease occurred in the 367 athletes over a follow-up period of 7.4 ± 5 years.

Conclusion

Exercise-induced ventricular tachyarrhythmias were present in a sizable minority of highly trained athletes without heart disease. These arrhythmias proved to be benign and not associated with adverse events or later development of cardiovascular disease.

Introduction

Frequent and complex ventricular tachyarrhythmias in trained athletes without cardiovascular abnormalities, identified by ambulatory (Holter) monitoring, have been considered a clinically benign expression not infrequently associated with the physiologic athlete’s heart.1, 2, 3, 4, 5 These arrhythmias, when present at rest, usually disappear during exercise as well as after periods of deconditioning,6 do not reappear in a significant degree after resumption of training3 and are unrelated to the magnitude of physiologic left ventricular hypertrophy.2

Notably, however, ventricular arrhythmias occurring during exercise in patients with structural heart disease, including coronary artery disease in older patients7, 8 or arrhythmogenic right ventricular cardiomyopathy (ARVC) and ion channelopathies in young patients,9, 10 have been considered risk markers for sudden cardiac death. At present, the clinical significance of exercise-induced ventricular arrhythmias in trained athletes without apparent cardiovascular disease remains unresolved. Therefore, the objectives of this study were to clarify the clinical significance and consequences of ventricular tachyarrhythmias occurring during exercise in a large population of young athletes without evident cardiovascular abnormalities and to assess their impact on eligibility for participation in competitive sports.

Section snippets

Patient selection

Since 1982, the Italian government has required by law that all citizens participating in officially sanctioned competitive sports undergo preparticipation screening to exclude the presence of cardiovascular diseases that would be associated with an increased risk of sudden death during training and competition.11 At the Institute of Sports Medicine and Science (Rome), all competitive athletes, selected for inclusion in national and Olympic teams, undergo systematic medical evaluation that

Ventricular tachyarrhythmias during exercise stress testing

Of the 5011 athletes without structural heart disease in the study group, 367 (7.3%) showed ≥1 premature ventricular beat (PVB), including 331 (6.6%) with ≤10 PVBs (mean 5.2 ± 4; range 1–9) and 36 (0.7%) with >10 PVBs (range 10–173; mean 45 ± 38), and/or ≥1 ventricular couplets (range 1–58; mean 9 ± 15), and/or ≥1 bursts of nonsustained ventricular tachycardia (NSVT; mean 2 ± 4) of 3–15 beats in length at rates of 145–188 beats/min (Table 1).

In most of the athletes with arrhythmias (251 of 367

Discussion

The significance of ventricular tachyarrhythmias in trained athletes has been an issue of concern to those practitioners dedicated to the care of this population and the cardiology community.14 This sensitivity is largely related to the visibility afforded by sudden death in young competitive athletes over the last 30 years, mainly in those with underlying and usually unsuspected cardiovascular disease.15, 16, 17, 18 However, ventricular arrhythmias are not uncommon in athletes without evidence

Conclusion

In a large consecutive cohort of young highly trained and elite athletes, ventricular tachyarrhythmias induced by exercise testing were found in 7%. However, in only 0.3% of the athletes did these arrhythmias justify consideration for radiofrequency ablation. These arrhythmias, either PVBs and/or complex forms, showed marked spontaneous reduction over time in the vast majority of athletes, and were not associated with cardiovascular morbidity or mortality over the follow-up period, despite

References (36)

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