Sex-specific performance of electrocardiographic criteria for left ventricular hypertrophy in elite athletes

In athletes, left ventricular hypertrophy (LVH) criteria based on electrocardiograms (ECGs) have been validated almost exclusively in men using echocardiography. Sex-specific cardiac magnetic resonance (CMR) validation is lacking.

To evaluate ECG-LVH criteria against contrast-enhanced CMR in male and female elite athletes.

Cross-sectional study in healthy elite athletes. Eight ECG-LVH criteria of voltages and products and QRS duration were quantified using automated ECG analysis, and compared to CMR-derived LVH indicators (indexed left ventricular mass (LVM) and maximum left ventricular wall thickness (maxLVWT). Primary metrics of interest were sex-specific correlations (ρ) between ECG-LVH criteria and LVM/maxLVWT. Secondary metrics included discriminative performance (AUROC) and sensitivity at a 95%-specificity level for detecting increased LVM or maxLVWT.

Among 209 elite athletes (median age 25, 45% women), men more frequently met one or more voltage criteria than women (64% vs 45%, P = .010). In men, no ECG-LVH criteria showed meaningful correlations or discriminative performance for LVM or maxLVWT. Only QRS duration demonstrated discriminative performance (AUROC: LVM 0.67; maxLVWT 0.74). In women, all voltage and product criteria correlated with LVM (ρ = 0.25-0.45) with acceptable discrimination (AUROC: 0.63-0.73). Peguero-Lo Presti, Cornell-, and Modified Sum of 12-Lead Product showed moderate performance (sensitivities: 24%-29%) at 95% specificity in female athletes. Overall, increased precordial QRS voltages were independently correlated with lower extracellular volume (β = -0.3 mV per %ECV, P < .001).

In elite athletes, ECG-LVH criteria, except for QRS duration, lack diagnostic value for LVH in men. Voltage criteria may have diagnostic potential in women.