1. Which of the following ECG findings is typically considered a normal variant in asymptomatic athletes with no significant family history?
A: Mobitz Type II 2nd AV block
B: Prolonged QT interval (QTc ≥ 480 ms for females)
C: Incomplete Right Bundle Branch Block (rSR’ pattern in lead V1 and qRS pattern in V6 with QRS duration <120 ms)
D: Profound sinus bradycardia (<30 beats/min or sinus pauses ≥3 s)
Explanation: Incomplete Right Bundle Branch Block, defined by an rSR’ pattern in lead V1 and a qRS pattern in lead V6 with QRS duration <120 ms, is listed as a ‘Normal ECG finding’ and considered a normal variant in asymptomatic athletes with no significant family history, not requiring further evaluation. Mobitz Type II 2nd AV block, prolonged QT interval, and profound sinus bradycardia are typically considered abnormal or profound findings that may require further investigation.
2. What heart rate range is ideally recommended for measuring the QT interval corrected for heart rate (QTc) using Bazett’s formula?
A: Less than 50 beats/min
B: 60 to 90 beats/min
C: 90 to 120 beats/min
D: Greater than 100 beats/min
Explanation: The QT interval corrected for heart rate is ideally measured using Bazett’s formula with heart rates between 60 and 90 beats/min.
3. What is the recommended action if a QTc value is borderline or abnormal and the heart rate is less than 50 beats/min?
A: Proceed directly to an exercise ECG test without repeating the resting ECG.
B: Repeat the ECG after mild aerobic activity.
C: Immediately refer to a heart rhythm specialist.
D: Disregard the borderline QTc as it is likely a normal variant.
Explanation: If the QTc value is borderline or abnormal and the heart rate is less than 50 beats/min, it is recommended to repeat the ECG after mild aerobic activity. If the heart rate is greater than 100 beats/min, repeating the ECG after a longer resting period is advised.
4. Which of the following describes a ‘Black athlete repolarization variant’ considered a normal ECG finding?
A: T-wave inversion in leads V1-V3 in athletes age <16 years.
B: J-point elevation and convex (‘domed’) ST-segment elevation followed by T-wave inversion in leads V1-V4 in black athletes.
C: PR interval <120 ms with a delta wave and wide QRS (≥120 ms).
D: QRS duration ≥140 ms.
Explanation: The ‘Black athlete repolarization variant’ is defined as J-point elevation and convex (‘domed’) ST-segment elevation followed by T-wave inversion in leads V1-V4 specifically in black athletes. T-wave inversion in V1-V3 for athletes <16 years is a ‘Juvenile T-wave pattern’. PR interval <120 ms with a delta wave and wide QRS is indicative of ‘Ventricular pre-excitation’, and QRS duration ≥140 ms is considered ‘Profound nonspecific intra-ventricular conduction delay’, both of which are not typical normal findings.
5. Which of the following is true regarding sinus bradycardia in athletes?
A: Any sinus bradycardia, regardless of heart rate, requires immediate cardiological referral.
B: Heart rates of ≥30 beats/min are considered normal in highly trained athletes in the absence of symptoms.
C: Sinus bradycardia should persist with the onset of physical activity.
D: Sinus bradycardia with heart rates between 50-60 beats/min always indicates a pathological condition.
Explanation: In the absence of symptoms, heart rates ≥30 beats/min are considered normal in highly trained athletes. Sinus rhythm should resume and bradycardia should resolve with the onset of physical activity. Profound sinus bradycardia (<30 beats/min or sinus pauses ≥3 s) would warrant further investigation.
6. Which of the following ECG findings is generally considered a normal variant in asymptomatic athletes and typically does not require further evaluation, assuming no significant family history?
A: Brugada Type 1 pattern
B: Profound sinus bradycardia (<30 beats/min or sinus pauses ≥3s)
C: Increased QRS voltage (isolated QRS voltage criteria for left ventricular hypertrophy or right ventricular hypertrophy)
D: Mobitz Type II 2nd AV block
Explanation: Increased QRS voltage, specifically isolated QRS voltage criteria for left (SV1+RV5) or right ventricular hypertrophy (RV1+SV5 or SV6 >1.1 mV), is considered a normal variant in athletes and does not require further evaluation in asymptomatic athletes with no significant family history. Brugada Type 1 pattern, profound sinus bradycardia, and Mobitz Type II 2nd AV block are considered abnormal or require further investigation.
7. Which of the following best defines ‘Incomplete RBBB’ as a normal ECG finding in athletes?
A: rSR’ pattern in lead V1 and a qRS pattern in lead V6 with QRS duration <120 ms.
B: rSR’ pattern in lead V1 and a qRS pattern in lead V6 with QRS duration ≥120 ms.
C: J-point elevation and convex ST-segment elevation followed by T-wave inversion in leads V1-V4.
D: PR interval <120 ms with a delta wave (slurred upstroke in the QRS complex) and wide QRS (≥120 ms).
Explanation: Incomplete RBBB is defined as an rSR’ pattern in lead V1 and a qRS pattern in lead V6 with a QRS duration of <120 ms. Option B describes complete RBBB if the QRS duration is ≥120 ms. Option C describes the Black athlete repolarization variant. Option D describes ventricular pre-excitation.
8. An athlete presents with a prolonged QTc interval (e.g., QTc ≥470 ms for males or ≥480 ms for females). What is the initial recommended action?
A: Immediately refer to a heart rhythm specialist for an electrophysiological study.
B: Repeat resting ECG on a separate day, review for QT prolonging medication, and acquire ECG of 1st-degree relatives if possible.
C: Schedule an immediate cardiac MRI.
D: Prescribe beta-blockers without further investigation.
Explanation: For a prolonged QTc interval, the initial recommendations include repeating a resting ECG on a separate day, reviewing for any QT prolonging medications, and acquiring an ECG from 1st-degree relatives if feasible. Referral to a heart rhythm specialist or sports cardiologist is specifically considered for a QTc ≥500 ms.
9. An asymptomatic athlete presents with profound sinus bradycardia (<30 beats/min or sinus pauses ≥3s). What is the initial recommended step?
A: Immediate referral for pacemaker implantation.
B: Repeat ECG after mild aerobic activity.
C: Direct referral to a cardiac surgeon.
D: Prescribe atropine to increase heart rate.
Explanation: For profound sinus bradycardia (<30 beats/min or sinus pauses ≥3s), the initial recommendation is to repeat the ECG after mild aerobic activity to assess the heart rate response. Further testing is considered based on clinical suspicion.
10. The QT interval corrected for heart rate (QTc) is ideally measured using Bazett’s formula under which heart rate conditions?
A: Heart rates <50 beats/min.
B: Heart rates between 60 and 90 beats/min.
C: Heart rates >100 beats/min.
D: Heart rates exclusively during vigorous exercise.
Explanation: The QT interval corrected for heart rate (QTc) is ideally measured using Bazett’s formula when heart rates are between 60 and 90 beats/min. If the heart rate is outside this range (e.g., <50 beats/min or >100 beats/min) and the QTc value is borderline or abnormal, repeating the ECG after mild aerobic activity or a longer resting period, respectively, is advised.
11. Which statement accurately describes the general clinical significance of isolated borderline ECG findings in athletes and the recommendation when multiple borderline findings are present?
A: Isolated borderline findings always indicate underlying pathological cardiovascular disease, requiring immediate extensive investigation.
B: Isolated borderline findings often represent normal variants or physiological cardiac remodeling, but the presence of two or more borderline findings may warrant additional investigation.
C: Borderline findings are always benign and never require any further evaluation, regardless of their number.
D: Borderline findings necessitate immediate referral to an electrophysiologist for an invasive procedure.
Explanation: Recent data suggest that isolated ECG findings categorized as borderline in athletes often represent normal physiological cardiac remodeling or variants and do not typically indicate pathological cardiac disease. However, if an athlete presents with two or more borderline findings, further investigation may be warranted.
12. What is the recommended approach for ‘juvenile ECG pattern’ characterized by TWI (T-wave inversion) confined to the anterior precordial leads in adolescent athletes up to 16 years old?
A: It should be immediately investigated with a cardiac MRI to rule out cardiomyopathy.
B: It is considered a normal age-related pattern and typically does not require further investigation in the absence of other clinical or ECG features of cardiomyopathy.
C: It indicates a high risk of sudden cardiac death and mandates immediate sports cessation.
D: It requires an exercise ECG test to assess for myocardial ischemia.
Explanation: TWI confined to the anterior precordial leads in adolescent athletes up to 16 years of age may be considered a normal age-related ‘juvenile ECG pattern’ and should not result in further investigation if there are no other clinical or ECG features suggesting cardiomyopathy.
13. What is the correlation of isolated axis deviation or voltage criteria for atrial enlargement with cardiac pathology in athletes?
A: These findings always correlate with major structural or functional cardiac abnormalities.
B: They are highly specific for myocardial disease and require immediate treatment.
C: They account for a significant percentage of abnormal ECG patterns but do not correlate with cardiac pathology, and echocardiographic evaluation often fails to identify major structural or functional abnormalities.
D: They are contraindications to participation in competitive sports.
Explanation: Axis deviation and voltage criteria for atrial enlargement are common ‘abnormal’ ECG patterns in athletes, accounting for over 40% of such findings. However, they generally do not correlate with cardiac pathology, and studies have shown that echocardiographic evaluation in athletes with these isolated findings often fails to identify major structural or functional abnormalities.
14. What is the recommended initial evaluation for an athlete who presents with two or more borderline ECG findings?
A: Direct referral for an invasive electrophysiology study.
B: Immediate genetic testing for inherited cardiac conditions.
C: Echocardiography, with consideration for additional testing based on clinical suspicion.
D: No further evaluation is needed, as borderline findings are by definition not clinically significant.
Explanation: For an athlete presenting with two or more borderline ECG findings, echocardiography is the recommended initial evaluation, with additional testing to be considered based on clinical suspicion.
15. If an athlete’s QTc value is found to be borderline or abnormal, what is a key recommendation regarding the ECG measurement?
A: Immediately prescribe beta-blockers without further assessment.
B: Perform an exercise ECG test to check for QT shortening.
C: Consider repeating the ECG after mild aerobic activity if the heart rate is <50 beats/min, or after a longer resting period if the heart rate is >100 beats/min.
D: Refer directly for an implantable cardioverter-defibrillator (ICD) evaluation.
Explanation: When an athlete’s QTc value is borderline or abnormal, it is recommended to consider repeating the ECG. This repeat should be done after mild aerobic activity if the heart rate is below 50 beats/min, or after a longer resting period if the heart rate is above 100 beats/min, to ensure a more accurate measurement.
16. What QTc duration in an athlete is considered ‘marked QT prolongation’ and prompts a direct referral to a heart rhythm specialist or sports cardiologist?
A: QTc ≥ 450 ms
B: QTc ≥ 470 ms
C: QTc ≥ 480 ms
D: QTc ≥ 500 ms
Explanation: A QTc ≥ 500 ms is defined as marked QT prolongation, and direct referral to a heart rhythm specialist or sports cardiologist should be considered.
17. In which specific group of athletes might T-wave inversion confined to the anterior precordial leads be considered a normal age-related pattern, often referred to as a ‘juvenile ECG pattern’?
A: Adult athletes over 30 years old.
B: Adolescent athletes up to the age of 16 years old.
C: Female athletes of all ages.
D: Athletes with a history of hypertension.
Explanation: T-wave inversion confined to the anterior precordial leads may be considered a normal age-related pattern in adolescent athletes up to the age of 16 years old.
18. For an athlete with a prolonged QTc, what is one of the initial recommended evaluation steps?
A: Immediately schedule an invasive electrophysiology study.
B: Refer directly for cardiac surgery.
C: Repeat a resting ECG on a separate day and review for QT prolonging medication.
D: Start antiarrhythmic medication without further testing.
Explanation: For prolonged QTc, initial recommended evaluation steps include repeating a resting ECG on a separate day and reviewing for QT prolonging medication.
19. If an athlete presents with J-point elevation and convex ST-segment elevation in anterior leads (V1 to V4) followed by TWI, what is the typical recommendation in the absence of other clinical or ECG features of cardiomyopathy?
A: It is regarded as a normal variant and should not result in further investigation.
B: It necessitates immediate cardiac catheterization.
C: It indicates an urgent need for an implantable cardioverter-defibrillator (ICD).
D: It requires long-term antiarrhythmic drug therapy.
Explanation: J-point elevation and convex ST-segment elevation in the anterior leads (V1 to V4) followed by TWI is regarded as a normal variant and should not result in further investigation, in the absence of other clinical or ECG features of cardiomyopathy.
20. An athlete presents with a QTc interval of ≥500 ms on an ECG. What is the most appropriate next step?
A: Initiate immediate antiarrhythmic medication.
B: Repeat a resting ECG on a separate day and review for QT prolonging medication.
C: Direct referral to a heart rhythm specialist or sports cardiologist.
D: Perform an exercise ECG test immediately.
Explanation: For a QTc ≥500 ms, the international recommendations advise considering a direct referral to a heart rhythm specialist or sports cardiologist. While repeating an ECG and reviewing medications are part of the overall evaluation for prolonged QTc, a value this high warrants specialist input directly.
21. For T-wave inversion in the lateral or inferolateral leads, which of the following diagnostic tools is considered superior for detecting conditions like apical HCM, LVH localized to the free lateral wall, ARVC with predominant left ventricular involvement, and myocarditis?
A: Exercise ECG test
B: Minimum 24-hour ECG monitor
C: Cardiac Magnetic Resonance (CMR)
D: Standard echocardiography
Explanation: Cardiac Magnetic Resonance (CMR) is recommended as a routine diagnostic test for this ECG phenotype and is superior to echocardiography for detecting apical HCM, LVH localized to the free lateral wall, ARVC with predominant left ventricular involvement, and myocarditis.
22. In an athlete with ventricular pre-excitation (WPW), what finding on an exercise ECG test denotes a low-risk pathway?
A: Persistence of the delta wave throughout exercise.
B: Abrupt cessation of the delta wave (pre-excitation) on exercise ECG.
C: Widening of the QRS complex during exercise.
D: Development of ST-segment depression during exercise.
Explanation: Abrupt cessation of the delta wave (pre-excitation) on exercise ECG denotes a low-risk pathway for ventricular pre-excitation.
23. An athlete’s ECG reveals multiple premature ventricular contractions (≥2 PVCs per 10-second tracing). What is the minimum recommended evaluation to exclude underlying structural heart disease?
A: A repeat ECG at rest.
B: An ambulatory Holter monitor, echocardiogram, and exercise ECG test.
C: Genetic testing and family screening only.
D: Prescription of a beta-blocker.
Explanation: For multiple premature ventricular contractions (≥2 PVCs), the finding should prompt more extensive evaluation to exclude underlying structural heart disease. At a minimum, an ambulatory Holter monitor, echocardiogram, and exercise ECG test are recommended.
24. What QTc interval is considered prolonged in a male, warranting further investigation?
A: QTc ≥ 450 ms
B: QTc ≥ 460 ms
C: QTc ≥ 470 ms
D: QTc ≥ 500 ms
Explanation: A prolonged QT interval is defined as a QTc ≥ 470 ms in males and QTc ≥ 480 ms in females. A QTc ≥ 500 ms is considered marked QT prolongation.
25. T-wave inversion in the lateral or inferolateral leads on an ECG may suggest several potential cardiac diseases. Which of the following is NOT typically listed as a potential cardiac disease associated with this finding?
A: Hypertrophic Cardiomyopathy (HCM)
B: Dilated Cardiomyopathy (DCM)
C: Left Ventricular Non-Compaction (LVNC)
D: Anomalous coronary arteries
Explanation: T-wave inversion in the lateral or inferolateral leads is associated with potential cardiac diseases such as HCM, DCM, LVNC, ARVC (with predominant LV involvement), and Myocarditis. Anomalous coronary arteries are generally not detectable by ECG.
26. A patient’s ECG shows intermittently non-conducted P waves with a fixed PR interval. What type of AV block does this describe, and what is an essential next step in evaluation?
A: First-degree AV block; no further action needed.
B: Mobitz Type I AV block; repeat ECG in 6 months.
C: Mobitz Type II AV block; further evaluation including echocardiogram, ambulatory ECG monitor, and referral to an electrophysiologist.
D: Third-degree AV block; immediate pacemaker implantation.
Explanation: Intermittently non-conducted P waves with a fixed PR interval describe Mobitz Type II AV block. If detected, further evaluation includes an echocardiogram, ambulatory ECG monitor, and exercise ECG test. Referral to an electrophysiologist is essential.
27. Which of the following ECG characteristics is defining for a Brugada Type 1 pattern?
A: ST-segment depression in leads V1-V3 with a positive T-wave.
B: Coved-type ST-segment elevation ≥ 2 mm in ≥ 1 leads in V1-V3, followed by a negative symmetric T-wave.
C: Saddle-back type ST-segment elevation < 2 mm in V1-V3 with a positive T-wave.
D: Q waves ≥ 40 ms in leads V1-V3 with ST-segment elevation.
Explanation: A Brugada Type 1 pattern is characterized by a coved-type ST-segment elevation of ≥ 2 mm (high take-off) with a downsloping ST-segment elevation followed by a negative symmetric T-wave in at least one lead in V1-V3.
28. What initial evaluation is recommended if a Mobitz Type II atrioventricular (AV) block is detected on an ECG?
A: Immediate antiarrhythmic medication and a stress test.
B: An echocardiogram, ambulatory ECG monitor, and exercise ECG test.
C: Only an ambulatory ECG monitor to confirm the diagnosis.
D: Direct referral for pacemaker implantation without further testing.
Explanation: If Mobitz Type II AV block or complete AV block is detected, further evaluation should include an echocardiogram, an ambulatory ECG monitor, and an exercise ECG test. Based on these results, laboratory testing and cardiac MRI may be considered, and referral to an electrophysiologist is essential.
29. What is a key ECG criterion for diagnosing ventricular pre-excitation (e.g., Wolff-Parkinson-White syndrome)?
A: PR interval > 200 ms with a narrow QRS complex.
B: PR interval < 120 ms with a delta wave and a wide QRS (≥ 120 ms).
C: Normal PR interval with inverted T-waves in precordial leads.
D: ST-segment elevation in leads V1-V3 without a delta wave.
Explanation: Ventricular pre-excitation is characterized by a PR interval < 120 ms, the presence of a delta wave (a slurred upstroke in the QRS complex), and a wide QRS complex (≥ 120 ms).
30. For an athlete presenting with an indeterminate Brugada pattern on ECG, which of the following is a recommended next step for evaluation?
A: Immediate implantation of an implantable cardioverter-defibrillator (ICD).
B: Consideration of a high precordial lead ECG with leads V1 and V2 in the 2nd intercostal space.
C: Initiation of antiarrhythmic medication without further testing.
D: A 24-hour ambulatory ECG monitor as the sole follow-up.
Explanation: If the Brugada pattern is indeterminate, consider a high precordial lead ECG with leads V1 and V2 in the 2nd intercostal space or sodium channel blockade.
31. What is the definition of profound sinus bradycardia that warrants further investigation in an athlete, and what is an initial recommended step?
A: Heart rate <40 beats/min with immediate referral to an electrophysiologist.
B: Heart rate <30 beats/min or sinus pauses ≥3 seconds, with a repeat ECG after mild aerobic activity.
C: Heart rate <50 beats/min and symptoms, requiring an immediate exercise stress test.
D: Heart rate <35 beats/min at rest, necessitating cardiac MRI.
Explanation: Profound sinus bradycardia is defined as <30 beats/min or sinus pauses ≥3 seconds. The initial recommended step is to repeat the ECG after mild aerobic activity.
32. For an athlete with ventricular pre-excitation (WPW), when should an electrophysiological (EP) study for risk assessment be considered?
A: Only if the delta wave disappears abruptly on exercise ECG.
B: If a low-risk accessory pathway cannot be confirmed by non-invasive testing, or for moderate to high intensity sports.
C: Only for athletes engaging in low-intensity sports.
D: Never, as ventricular pre-excitation is always a benign finding in athletes.
Explanation: An EP study for risk assessment should be considered if a low accessory pathway cannot be confirmed by non-invasive testing. Additionally, considering an EP study for moderate to high intensity sports is recommended. Abrupt cessation of the delta wave on exercise ECG denotes a low-risk pathway, which would typically reduce the immediate need for an EP study.
33. What is the recommended evaluation if Mobitz Type II AV block or complete AV block is detected?
A: Only an echocardiogram and a 24-hour ambulatory ECG monitor.
B: An echocardiogram, ambulatory ECG monitor, and exercise ECG test, followed by referral to an electrophysiologist.
C: Direct genetic testing without further cardiac imaging.
D: No further evaluation if the patient is asymptomatic.
Explanation: If Mobitz Type II AV block or complete AV block is detected, further evaluation includes an echocardiogram, ambulatory ECG monitor, and exercise ECG test. Based on these results, laboratory testing and cardiac MRI may be considered, and referral to an electrophysiologist is essential.
34. What is the leading cause of mortality in athletes during sport?
A: Traumatic brain injury
B: Dehydration
C: Cardiovascular-related sudden death
D: Heatstroke
Explanation: Cardiovascular-related sudden death is the leading cause of mortality in athletes during sport.
35. Despite a normal ECG, when should further assessment be considered for an athlete according to the recommendations?
A: Only if the athlete requests it.
B: Only after a year of consistent athletic training.
C: In the presence of cardiac symptoms or a family history of inherited cardiovascular disease or premature sudden cardiac death (SCD).
D: If the athlete is participating in a new sport.
Explanation: The document highlights that a normal ECG should not preclude further assessment if the athlete has cardiac symptoms or a family history of inherited cardiovascular disease or premature sudden cardiac death.
36. Which of the following conditions may an electrocardiogram (ECG) be unable to detect, as noted in the limitations section?
A: Sinus bradycardia
B: Ventricular pre-excitation
C: Anomalous coronary arteries
D: Left ventricular hypertrophy
Explanation: The ECG is unable to detect anomalous coronary arteries, premature coronary atherosclerosis, and aortopathies.
