Jane E. Crosson, MD

CASE

15.1

Patient History

A 19-year-old college athlete underwent a standard precollegiate ECG screening (Figure 15.1.1).

Figure 15.1.1

Question

Should additional testing be performed, or is she cleared to participate?

Discussion

The ECG demonstrates T-wave inversions in the septal precordial leads in a 19-year-old, a finding that should prompt further evaluation of arrhythmogenic right ventricular cardiomyopathy (ARVC). T-wave inversions in the precordial leads are normal in pediatric patients, but the axis is typically upright by the age of 14. Given these findings, a signal-averaged ECG was performed (Figure 15.1.2), which demonstrated abnormal depolarization. Normal criteria for signal-averaged ECGs include a total filtered QRS duration ≤ 114 ms, duration of high-frequency, low-amplitude signals below 40 μV ≤ 38 ms, and the root mean squared voltage in the terminal 40 ms of the QRS complex ≥ 20 μV. While the patient’s signal-averaged ECG is abnormal, establishing a diagnosis of ARVC requires additional criteria including radiographic abnormalities seen with advanced cardiac imaging.¹ The patient is currently undergoing further testing to determine whether the diagnostic criteria for ARVC are fulfilled.

Figure 15.1.2

Reference

1. Marcus FI, McKenna WJ, Sherrill D, et al. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: Proposed modification of the task force criteria. Circulation. 2010;121:1533–1541.

Patient History

ECG of a 32-year-old male with palpitations and recurrent syncope while pitching in baseball. He collapsed during competition and was cardioverted from ventricular flutter (rate 260 bpm).

Figure 15.2.1

Questions

1. What is the ECG abnormality?

2. What cardiovascular condition is likely to cause the ECG abnormality and cardiac arrest?

Discussion

The ECG demonstrates normal sinus rhythm with left ventricular hypertrophy with strain and deep symmetrical T wave inversion in leads V₂–V₅. Apical hypertrophic cardiomyopathy was confirmed by an echocardiogram and magnetic resonance imaging with gadolinium enhancement of the apical septum.

Patient History

A 34-year-old female mountain biker, training 30 hours per week and internationally competitive, presents for a yearly check-up. During thorough history taking, she admits that her results have declined somewhat over the last year, despite an intensified training schedule.

Figure 15.3.1

Question

Can she continue to compete or not?

Discussion

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