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Original research
Impact of the distance from the chest wall to the heart on surface ECG voltage in athletes
  1. Kristofer Hedman1,2,
  2. Alessandro Patti3,4,
  3. Kegan J Moneghetti1,3,
  4. David Hsu1,3,
  5. Jeffrey W Christle1,3,
  6. Euan Ashley1,3,
  7. David Hadley5,
  8. Francois Haddad1,3,
  9. Victor Froelicher1,3
  1. 1Department of Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA
  2. 2Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköpings universitet, Linköping, Sweden
  3. 3Stanford Sports Cardiology, Stanford University, Stanford, California, USA
  4. 4Sport and Exercise Medicine Division, Department of Medicine, University of Padova, Padova, Italy
  5. 5Cardiac Insight, Bellevue, Washington, USA
  1. Correspondence to Dr Kristofer Hedman; kristofer.hedman{at}liu.se

Abstract

Objective Available ECG criteria for detection of left ventricular (LV) hypertrophy have been reported to have limited diagnostic capability. Our goal was to describe how the distance between the chest wall and the left ventricle determined by echocardiography affected the relationship between ECG voltage and LV mass (LVM) in athletes.

Methods We retrospectively evaluated digitised ECG data from college athletes undergoing routine echocardiography as part of their preparticipation evaluation. Along with LV mass and volume, we determined the chest wall–LV distance in the parasternal short-axis and long-axis views from two-dimensional transthoracic echocardiographic images and explored the relation with ECG QRS voltages in all leads, as well as summed voltages as included in six major ECG-LVH criteria.

Results 239 athletes (43 women) were included (age 19±1 years). In men, greater LV–chest wall distance was associated with higher R-wave amplitudes in leads aVL and I (R=0.20 and R=0.25, both p<0.01), while in women greater distance was associated with higher R-amplitudes in V5 and V6 (R=0.42 and R=0.34, both p<0.01). In women, the chest wall–LV distance was the only variable independently (and positively) associated with R V5 voltage, while LVM, height and weight contributed to the relationship in men.

Conclusions The chest wall–LV distance was weakly associated with ECG voltage in athletes. Inconsistent associations in men and women imply different intrathoracic factors affecting impedance and conductance between sexes. This may help explain the poor relationship between QRS voltage and LVM in athletes.

  • electrocardiography
  • pre-participation evaluation
  • athlete’s heart
  • left ventricular hypertrophy
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjsem-2019-000696

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    Footnotes

    • Twitter @KristoferHedman

    • Contributors KH, FH and VF contributed to the conception or design of the study. VF, DHa and FH acquired the data and managed the database. KJM and FH acquired the echocardiographic images and measures. All authors contributed to the interpretation of data for the work. KH drafted the manuscript. All authors critically revised the manuscript and gave final approval and agree to be accountable for all aspects of work ensuring integrity and accuracy.

    • Funding KH received funding through postdoctoral grants from the Fulbright Commission, the Swedish Heart Foundation, the Swedish Society of Medicine and the County Council of Östergötland, Sweden. In addition, general funding from the Stanford Cardiovascular Institute was used to complete this study.

    • Competing interests VF and DHa are developers and part-owners of the ECG system used to acquire the digitised ECG data (Cardea 20/20 ECG System, Cardic Insight, Bellevue, Washington, USA).

    • Patient consent for publication Not required.

    • Ethics approval The study was approved by the institutional review board at Stanford University (approval numbers 12245 and 25673), and all subjects gave their written informed consent.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Deidentified data for this study are available upon reasonable request.