Sex-specific electrocardiographic criteria for left ventricular hypertrophy in young athletes

Left ventricular hypertrophy is a common electrocardiographic (ECG) finding in athletes, but existing amplitude-based criteria often generate false positives.

The purpose of this study was to reevaluate ECG criteria for screening athletes for left ventricular hypertrophy by considering QRS amplitude measurements and demographic factors, using data from an extensive digital ECG database.

A retrospective analysis of digitized ECG records from 9254 young athletes aged 12-35 years underwent a preparticipation examination between 2010 and 2021. Univariate and multivariate analyses assessed R- and S-wave amplitudes by applying the 99th percentile for R waves and the 1st percentile for S waves and examined the Sokolow-Lyon (SL) precordial lead score and the limb lead (LL) score, adjusting for sex, sport, age, class (athlete classification [college, grade school, high school, and professional]), body mass index, and heart rate.

Our findings demonstrate significant sex differences in R- and S-wave voltages, with the highest R-wave voltages observed at the 99th percentile in lead V₄, V₅, or V₆ (4.4 mV for males and 3.3 mV for females). Multivariate analyses demonstrated that male athletes had significantly higher SL and LL scores than did females. While age, sport, ethnicity, and body mass index influenced SL and LL scores, their effect was much weaker than those of sex and impractical for general use.

Our findings demonstrate that the 99th percentile values for sex-specific QRS voltage criteria (SL score of >6.8 mV for males and >4.7 for females; LL score of >2.3 mV for males and >1.9 mV for females) can enhance ECG criteria in athletes by increasing sensitivity for pathological hypertrophy with modest decreases in specificity.