ECG Test - ECG Interpretation in Athletes

Which of the following ECG findings is typically considered a normal variant in asymptomatic athletes with no significant family history?

Mobitz Type II 2nd AV block

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Prolonged QT interval (QTc ≥ 480 ms for females)

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Incomplete Right Bundle Branch Block (rSR’ pattern in lead V1 and qRS pattern in V6 with QRS duration <120 ms)

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Profound sinus bradycardia (<30 beats/min or sinus pauses ≥3 s)

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According to international recommendations, what heart rate range is ideally recommended for measuring the QT interval corrected for heart rate (QTc) using Bazett’s formula?

Less than 50 beats/min

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60 to 90 beats/min

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90 to 120 beats/min

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Greater than 100 beats/min

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What is the recommended action if a QTc value is borderline or abnormal and the heart rate is less than 50 beats/min?

Proceed directly to an exercise ECG test without repeating the resting ECG.

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Repeat the ECG after mild aerobic activity.

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Immediately refer to a heart rhythm specialist.

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Disregard the borderline QTc as it is likely a normal variant.

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Which of the following describes a ‘Black athlete repolarization variant’ considered a normal ECG finding?

T-wave inversion in leads V1-V3 in athletes age <16 years.

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J-point elevation and convex (‘domed’) ST-segment elevation followed by T-wave inversion in leads V1-V4 in black athletes.

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PR interval <120 ms with a delta wave and wide QRS (≥120 ms).

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QRS duration ≥140 ms.

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Which of the following is true regarding sinus bradycardia in athletes?

Any sinus bradycardia, regardless of heart rate, requires immediate cardiological referral.

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Heart rates of ≥30 beats/min are considered normal in highly trained athletes in the absence of symptoms.

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Sinus bradycardia should persist with the onset of physical activity.

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Sinus bradycardia with heart rates between 50-60 beats/min always indicates a pathological condition.

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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?

Brugada Type 1 pattern

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Profound sinus bradycardia (<30 beats/min or sinus pauses ≥3s)

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Increased QRS voltage (isolated QRS voltage criteria for left ventricular hypertrophy or right ventricular hypertrophy)

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Mobitz Type II 2nd AV block

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According to international recommendations, which of the following best defines ‘Incomplete RBBB’ as a normal ECG finding in athletes?

rSR’ pattern in lead V1 and a qRS pattern in lead V6 with QRS duration <120 ms.

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rSR’ pattern in lead V1 and a qRS pattern in lead V6 with QRS duration ≥120 ms.

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J-point elevation and convex ST-segment elevation followed by T-wave inversion in leads V1-V4.

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PR interval <120 ms with a delta wave (slurred upstroke in the QRS complex) and wide QRS (≥120 ms).

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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?

Immediately refer to a heart rhythm specialist for an electrophysiological study.

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Repeat resting ECG on a separate day, review for QT prolonging medication, and acquire ECG of 1st-degree relatives if possible.

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Schedule an immediate cardiac MRI.

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Prescribe beta-blockers without further investigation.

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An asymptomatic athlete presents with profound sinus bradycardia (<30 beats/min or sinus pauses ≥3s). What is the initial recommended step?

Immediate referral for pacemaker implantation.

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Repeat ECG after mild aerobic activity.

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Direct referral to a cardiac surgeon.

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Prescribe atropine to increase heart rate.

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The QT interval corrected for heart rate (QTc) is ideally measured using Bazett’s formula under which heart rate conditions?

Heart rates <50 beats/min.

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Heart rates between 60 and 90 beats/min.

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Heart rates >100 beats/min.

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Heart rates exclusively during vigorous exercise.

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Which statement accurately describes the general clinical significance of isolated borderline ECG findings in athletes and the recommendation when multiple borderline findings are present?

Isolated borderline findings always indicate underlying pathological cardiovascular disease, requiring immediate extensive investigation.

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Isolated borderline findings often represent normal variants or physiological cardiac remodeling, but the presence of two or more borderline findings may warrant additional investigation.

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Borderline findings are always benign and never require any further evaluation, regardless of their number.

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Borderline findings necessitate immediate referral to an electrophysiologist for an invasive procedure.

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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?

It should be immediately investigated with a cardiac MRI to rule out cardiomyopathy.

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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.

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It indicates a high risk of sudden cardiac death and mandates immediate sports cessation.

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It requires an exercise ECG test to assess for myocardial ischemia.

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What is the correlation of isolated axis deviation or voltage criteria for atrial enlargement with cardiac pathology in athletes?

These findings always correlate with major structural or functional cardiac abnormalities.

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They are highly specific for myocardial disease and require immediate treatment.

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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.

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They are contraindications to participation in competitive sports.

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What is the recommended initial evaluation for an athlete who presents with two or more borderline ECG findings?

Direct referral for an invasive electrophysiology study.

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Immediate genetic testing for inherited cardiac conditions.

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Echocardiography, with consideration for additional testing based on clinical suspicion.

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No further evaluation is needed, as borderline findings are by definition not clinically significant.

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If an athlete’s QTc value is found to be borderline or abnormal, what is a key recommendation regarding the ECG measurement?

Immediately prescribe beta-blockers without further assessment.

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Perform an exercise ECG test to check for QT shortening.

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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.

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Refer directly for an implantable cardioverter-defibrillator (ICD) evaluation.

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According to international recommendations, what is the clinical significance of an athlete presenting with two or more borderline ECG findings?

It indicates a definite presence of pathologic cardiovascular disease.

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It is always considered a normal variant and requires no further action.

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It may warrant additional investigation, even if individual findings are considered borderline in isolation.

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It suggests an immediate need for surgical intervention.

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What QTc duration in an athlete is considered ‘marked QT prolongation’ and prompts a direct referral to a heart rhythm specialist or sports cardiologist?

QTc ≥ 450 ms

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QTc ≥ 470 ms

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QTc ≥ 480 ms

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QTc ≥ 500 ms

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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’?

Adult athletes over 30 years old.

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Adolescent athletes up to the age of 16 years old.

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Female athletes of all ages.

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Athletes with a history of hypertension.

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For an athlete with a prolonged QTc, what is one of the initial recommended evaluation steps?

Immediately schedule an invasive electrophysiology study.

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Refer directly for cardiac surgery.

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Repeat a resting ECG on a separate day and review for QT prolonging medication.

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Start antiarrhythmic medication without further testing.

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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?

It is regarded as a normal variant and should not result in further investigation.

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It necessitates immediate cardiac catheterization.

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It indicates an urgent need for an implantable cardioverter-defibrillator (ICD).

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It requires long-term antiarrhythmic drug therapy.

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An athlete presents with a QTc interval of ≥500 ms on an ECG. What is the most appropriate next step?

Initiate immediate antiarrhythmic medication.

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Repeat a resting ECG on a separate day and review for QT prolonging medication.

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Direct referral to a heart rhythm specialist or sports cardiologist.

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Perform an exercise ECG test immediately.

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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?

Exercise ECG test

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Minimum 24-hour ECG monitor

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Cardiac Magnetic Resonance (CMR)

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Standard echocardiography

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In an athlete with ventricular pre-excitation (WPW), what finding on an exercise ECG test denotes a low-risk pathway?

Persistence of the delta wave throughout exercise.

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Abrupt cessation of the delta wave (pre-excitation) on exercise ECG.

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Widening of the QRS complex during exercise.

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Development of ST-segment depression during exercise.

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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 repeat ECG at rest.

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An ambulatory Holter monitor, echocardiogram, and exercise ECG test.

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Genetic testing and family screening only.

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Prescription of a beta-blocker.

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According to international recommendations, what QTc interval is considered prolonged in a male, warranting further investigation?

QTc ≥ 450 ms

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QTc ≥ 460 ms

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QTc ≥ 470 ms

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QTc ≥ 500 ms

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Which of the following ECG patterns is characteristic of a Brugada Type 1 pattern?

ST-segment elevation in leads V4-V6 with an inverted T-wave.

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Coved pattern with initial ST-segment elevation ≥ 2 mm (high take-off), downsloping ST-segment elevation, and a negative symmetric T-wave in ≥ 1 leads in V1-V3.

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Saddle-back ST-segment elevation with T-wave inversion in leads I and aVL.

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Widespread ST-segment depression with T-wave flattening.

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What is the recommended initial evaluation for an athlete found to have multiple premature ventricular contractions (PVCs) on an ECG (defined as ≥2 PVCs per 10s tracing)?

Immediate antiarrhythmic medication and restriction from sports.

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Ambulatory Holter monitor and echocardiogram.

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Only an exercise ECG test.

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No further evaluation is typically needed as they are always benign.

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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?

Hypertrophic Cardiomyopathy (HCM)

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Dilated Cardiomyopathy (DCM)

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Left Ventricular Non-Compaction (LVNC)

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Anomalous coronary arteries

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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?

First-degree AV block; no further action needed.

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Mobitz Type I AV block; repeat ECG in 6 months.

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Mobitz Type II AV block; further evaluation including echocardiogram, ambulatory ECG monitor, and referral to an electrophysiologist.

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Third-degree AV block; immediate pacemaker implantation.

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Which of the following ECG characteristics is defining for a Brugada Type 1 pattern?

ST-segment depression in leads V1-V3 with a positive T-wave.

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Coved-type ST-segment elevation ≥ 2 mm in ≥ 1 leads in V1-V3, followed by a negative symmetric T-wave.

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Saddle-back type ST-segment elevation < 2 mm in V1-V3 with a positive T-wave.

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Q waves ≥ 40 ms in leads V1-V3 with ST-segment elevation.

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What initial evaluation is recommended if a Mobitz Type II atrioventricular (AV) block is detected on an ECG?

Immediate antiarrhythmic medication and a stress test.

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An echocardiogram, ambulatory ECG monitor, and exercise ECG test.

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Only an ambulatory ECG monitor to confirm the diagnosis.

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Direct referral for pacemaker implantation without further testing.

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What is a key ECG criterion for diagnosing ventricular pre-excitation (e.g., Wolff-Parkinson-White syndrome)?

PR interval > 200 ms with a narrow QRS complex.

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PR interval < 120 ms with a delta wave and a wide QRS (≥ 120 ms).

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Normal PR interval with inverted T-waves in precordial leads.

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ST-segment elevation in leads V1-V3 without a delta wave.

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What is the recommended approach for evaluating an athlete presenting with multiple (≥2) premature ventricular contractions (PVCs) on an ECG?

Reassurance, as PVCs are always benign in athletes.

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No further evaluation is needed unless symptoms are present.

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Prompt more extensive evaluation to exclude underlying structural heart disease, including at least an ambulatory Holter monitor and echocardiogram.

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Initiate antiarrhythmic therapy immediately.

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According to guidelines, a direct referral to a heart rhythm specialist or sports cardiologist is recommended for an athlete with a prolonged QTc interval when the QTc is at or above what value?

470 ms

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480 ms

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500 ms

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460 ms

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For an athlete presenting with an indeterminate Brugada pattern on ECG, which of the following is a recommended next step for evaluation?

Immediate implantation of an implantable cardioverter-defibrillator (ICD).

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Consideration of a high precordial lead ECG with leads V1 and V2 in the 2nd intercostal space.

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Initiation of antiarrhythmic medication without further testing.

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A 24-hour ambulatory ECG monitor as the sole follow-up.

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What is the definition of profound sinus bradycardia that warrants further investigation in an athlete, and what is an initial recommended step?

Heart rate <40 beats/min with immediate referral to an electrophysiologist.

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Heart rate <30 beats/min or sinus pauses ≥3 seconds, with a repeat ECG after mild aerobic activity.

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Heart rate <50 beats/min and symptoms, requiring an immediate exercise stress test.

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Heart rate <35 beats/min at rest, necessitating cardiac MRI.

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For an athlete with ventricular pre-excitation (WPW), when should an electrophysiological (EP) study for risk assessment be considered?

Only if the delta wave disappears abruptly on exercise ECG.

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If a low-risk accessory pathway cannot be confirmed by non-invasive testing, or for moderate to high intensity sports.

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Only for athletes engaging in low-intensity sports.

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Never, as ventricular pre-excitation is always a benign finding in athletes.

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What is the recommended evaluation if Mobitz Type II AV block or complete AV block is detected?

Only an echocardiogram and a 24-hour ambulatory ECG monitor.

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An echocardiogram, ambulatory ECG monitor, and exercise ECG test, followed by referral to an electrophysiologist.

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Direct genetic testing without further cardiac imaging.

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No further evaluation if the patient is asymptomatic.

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What is the leading cause of mortality in athletes during sport?

Traumatic brain injury

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Dehydration

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Cardiovascular-related sudden death

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Heatstroke

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Despite a normal ECG, when should further assessment be considered for an athlete according to the recommendations?

Only if the athlete requests it.

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Only after a year of consistent athletic training.

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In the presence of cardiac symptoms or a family history of inherited cardiovascular disease or premature sudden cardiac death (SCD).

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If the athlete is participating in a new sport.

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Which of the following conditions may an electrocardiogram (ECG) be unable to detect?

Sinus bradycardia

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Ventricular pre-excitation

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Anomalous coronary arteries

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Left ventricular hypertrophy

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ECG Tests (Quiz)

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ECG Test – ECG Interpretation in Athletes

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