ECG Quiz Answer: Can This College Athlete Compete?

John D. Cantwell, MD

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The 26th Bethesda Conference recommendations (1) are an excellent guide for making such decisions. We were initially hesitant to allow him to compete because the guidelines for congenital aortic valve stenosis base severity on the resting instantaneous peak valvular gradient on echocardiography, rather than mean gradient. A resting instantaneous gradient of 21 to 49 mm Hg would put him in the "moderate" ALIGN=RIGHT category and would restrict him to low static, low dynamic activities such as baseball, doubles tennis, archery, and golf.

In conferring with several members of the 26th Bethesda Conference task force, I learned they were referring to unicomissural congenital aortic stenosis (single hole, no leaflets). For a congenital bicuspid valve, the mean aortic valve pressure gradient, rather than the instantaneous gradient, was used to grade the severity. A mean gradient of less than 20 mm Hg put the patient in the mild category, allowing him to participate in all competitive sports as long as he is asymptomatic. (The instantaneous [or peak] gradient is the highest recorded; the mean gradient is the gradient that 50% of the multiple readings fall above and 50% fall below.)

His resting ECG (figure 2) suggested considerable left ventricular hypertrophy, yet on echocardiography his left ventricle was normal in size and wall thickness. Active patients can have a spectrum of ECG variations, and the echocardiogram is a much better guide to cardiac size than is the ECG.

The athlete was cleared for competition and was given information on endocarditis prophylaxis. A limited echocardiogram (2) will be done in 1 year.

References

1. Maron BJ, Mitchell JH: 26th Bethesda Conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. Med Sci Sports Exerc 1994;26(10 suppl):223-283
2. Murray PM, Cantwell JD, Heath DL, et al: The role of limited echocardiography in screening athletes. Am J Cardiol 1995;76(11):849-850

Dr Cantwell is director of preventive medicine and cardiac rehabilitation at Georgia Baptist Medical Center and clinical professor of medicine at Morehouse School of Medicine in Atlanta. He is a member of the editorial board of The Physician and Sportsmedicine and chief medical officer of the 1996 Centennial Olympic Games. Address correspondence to John D. Cantwell, MD, 340 Boulevard NE, Suite 200, Box 413, Atlanta, GA 30312.

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