How to evaluate premature ventricular beats in the athlete: critical review and proposal of a diagnostic algorithm

Abstract

Although premature ventricular beats (PVBs) in young people and athletes are usually benign, they may rarely mark underlying heart disease and risk of sudden cardiac death during sport. This review addresses the prevalence, clinical meaning and diagnostic/prognostic assessment of PVBs in the athlete. The article focuses on the characteristics of PVBs, such as the morphological pattern of the ectopic QRS and the response to exercise, which accurately stratify risk. We propose an algorithm to help the sport and exercise physician manage the athlete with PVBs. We also address (1) which athletes need more indepth investigation, including cardiac MRI to exclude an underlying pathological myocardial substrate, and (2) which athletes can remain eligible to competitive sports and who needs to be excluded.

Keywords: arrhythmias; athlete’s heart; disqualification; ectopic beats; eligibility; premature ventricular contraction; sudden cardiac death.

Figure 1

Morphologies of common premature ventricular beats in healthy athletes. Premature ventricular beat with negative QRS complex in V1 (left bundle branch block-like), precordial S/R transition in V4 and inferior QRS axis in the limb leads consistent with origin from the right ventricular outflow tract (A). Premature ventricular beat with negative QRS complex in V1 (left bundle branch block-like pattern), precordial S/R transition in V2/V3 and inferior QRS axis in the limb leads, suggestive of the origin from the left ventricular outflow tract (B). Premature ventricular beat with a relatively narrow QRS (120–130 ms) and typical right bundle branch block/superior axis configuration, suggestive of the origin from the posterior fascicle of the left bundle branch (C). Premature ventricular beat with a relatively narrow QRS (120–130 ms) and typical right bundle branch block/inferior axis configuration, suggestive of the origin from the anterior fascicle of the left bundle branch (D).

Figure 2

Coupling interval of premature ventricular beats. Normal coupling interval in a common (infundibular) pattern of premature ventricular beats (A). Short-coupled premature ventricular beats and terminal QRS slurring in the inferolateral leads followed by a flat ST segment in an athlete with idiopathic ventricular fibrillation (B).

Figure 3

Premature ventricular beats with a right bundle branch block-like pattern of the ectopic QRS and underlying left ventricular myocardial disease. Frequent and coupled premature ventricular beats with a right bundle branch block/superior axis QRS morphology during exercise testing in a 42-year-old martial arts athlete (A). Long-axis view (B) and short-axis view (C) of postcontrast cardiac magnetic resonance sequences showing a subepicardial/mid-myocardial ‘stria’ of late gadolinium enhancement involving the anterolateral, lateral and inferolateral segments of the left ventricular wall (arrows). Modified from Zorzi et al.

Figure 4

Premature ventricular beats with a left bundle branch block-like pattern of the ectopic QRS and underlying right ventricular myocardial disease. Premature ventricular beats with a left bundle branch block/intermediate axis pattern, associated with ECG abnormalities (low QRS voltages in the limb leads and negative T-waves in V1–V3 in non-ectopic beats), which increased during exercise testing in a 34-year-old female runner (A). Cine cardiac magnetic resonance sequences (four-chamber view) revealed right ventricular dilation with hypertrabeculation (diastolic frame) (B) and dyskinesia (arrow) of the right ventricular free wall (systole frame) consistent with arrhythmogenic cardiomyopathy (C).

Figure 5

Premature ventricular beats in an athlete with arrhythmic mitral valve prolapse. Premature ventricular beats with a right bundle branch block morphology and variable QRS axis, suggesting multiple ectopic foci in the left ventricular myocardium (A). Echocardiography (long-axis parasternal view) showing thickened and prolapsing mitral valve leaflets (arrow) (B). Postcontrast cardiac magnetic resonance sequence (apical four-chamber view) showing potentially arrhythmogenic areas of myocardial fibrosis/late gadolinium enhancement which are localised behind the posterior leaflet of the mitral valve (open arrow) and at the implant of the posterolateral papillary muscle (arrow) (C).

Figure 6

Proposed algorithm for evaluation of athletes with premature ventricular beats. *24-hour ECG monitoring should ideally have 12-lead configuration and include a training session. NEG, negative; POS, positive; PVBs, premature ventricular beats.