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Background: An increasing number of sporting bodies report unacceptably high levels of false-positive ECGs when undertaking pre-participation cardiac screening. To address this issue, modified ECG interpretation criteria have become available for use within athletes., Objective: This study assessed the accuracy of the new 2014 'Refined Criteria' against the 2013 Seattle Criteria and the 2010 European Society of Cardiology (ESC) recommendations in a cohort of Arabic, black and Caucasian athletes., Methods: 2491 male athletes (1367 Arabic, 748 black and 376 Caucasian) undertook pre-participation screening including a 12-lead ECG, with further investigation(s) upon indication., Results: Ten athletes (0.4%) were identified with cardiac pathology; seven with hypertrophic cardiomyopathy (HCM; five black and two Arabic) and three Arabs with Wolff-Parkinson-White syndrome (WPW). All three ECG criteria were 100% sensitive identifying all cases of HCM and WPW. The 2014 Refined Criteria reduced (p<0.0001) the prevalence of an abnormal ECG to 5.3% vs 11.6% (Seattle Criteria) and 22.3% (2010 ESC recommendations). The 2014 Refined Criteria significantly (p<0.0001) improved specificity (94.0%) across all ethnicities compared with the Seattle Criteria (87.5%) and ESC recommendations (76.6%). Black athletes continue to present a higher prevalence (p<0.0001) of abnormal ECGs compared with Arabic and Caucasian athletes (10% vs 3.6% and 2.1%)., Conclusions: The 2014 Refined Criteria for athlete ECG interpretation outperformed both the 2013 Seattle Criteria and the 2010 ESC recommendations by significantly reducing the number of false-positive ECGs in Arabic, black and Caucasian athletes while maintaining 100% sensitivity for serious cardiac pathologies., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

This is the third in a series of case studies on an individual with normal coronaries who sustained an idiopathic acute myocardial infarction . Bilateral pulmonary emboli almost 2 years post-myocardial infarction (MI) revealed coagulopathy as the cause. The original MI resulted in 16% myocardial scar tissue. An increasing number of patients are surviving MI, hence the burden for healthcare often shifts to heart failure. Accumulating evidence suggests high-intensity aerobic interval exercise (AHIT) is efficacious in improving cardiac function in health and disease. However, its impact on MI scar has never been assessed. Accordingly, the 50-year-old subject of this case study undertook 60 weeks of regular AHIT. Successive cardiac MRI results demonstrate, for the first time, a decrease in MI scar with exercise and, alongside mounting evidence of high efficacy and low risk, suggests AHIT may be increasingly important in future prevention and reversing of disease and or amelioration of symptoms.

Electrocardiographic changes are common in athletes. Differentiation of a physiological from a pathological substrate is important as ECG changes may indicate underlying cardiac disease placing the athlete at increased risk of sudden cardiac death. Deep T-wave inversions are uncommon in Caucasian athletes however; appear more prevalent in black athletes. Irrespective of the ethnic origin of the athlete, deep T-wave inversions require thorough follow-up. At present, 6 months de-training is recommended to assist in the differentiation of physiologic and pathologic changes where a definitive diagnosis is elusive through standard diagnostic techniques. This case study examines findings from a black and a Caucasian athlete presenting with deep T-wave inversions following a brief (ca.3 week) period of de-training resulting in normalisation of T-wave. These cases suggest that a shorter period of time may be sufficient in differentiating physiological from pathological mechanisms for deep T-wave inversions.

The pervasive public health message is that moderate amounts of endurance exercise help maintain optimal health and reduce cardiovascular risk. While not enough people meet national physical activity guidelines, there are some at the opposite end of the activity spectrum who far exceed the recommended 'dose' of exercise. The cardiovascular health consequences of single and/or multiple (lifelong) 'doses' of high-volume endurance exercise are currently being debated. Recent commentaries, case reports and case series data have posed the question whether you can 'overdose on exercise', and that is the focus of this brief review.

Around 6% of patients suffering an acute myocardial infarction (AMI) have normal coronary arteries. The mechanisms responsible are not fully known, but include hypercoagulable state, coronary endothelial dysfunction, aortic dissection, inflammation, coronary thrombosis, aortic wall stiffening, cocaine abuse, carbon monoxide poisoning and paradoxical embolism. Here, the case of a lifelong regular exerciser without risk factors for cardiovascular disease who suffered an AMI with normal coronaries is reported. Despite normal cardiac function on left ventriculography and echocardiography, late gadolinium enhancement by cardiac magnetic resonance (CMR) revealed significant cardiac necrosis. The long-term prognosis is favourable with low rates of coronary morbidity and mortality. Acute chest pain should not be considered as benign and warrants medical investigation.

Collapse after prolonged endurance exercise is common and usually benign. This case study reports a triathlete who suffered a vaso-vagal associated collapsed after exercise. Misdiagnosis of myocardial injury in the presence of elevated cardiac troponins and ECG anomalies led to inappropriate management and highlights the difficulty in treating the collapsed athlete following arduous exercise.

We report the case of an experienced, highly trained marathon runner who died suddenly while running. On post-mortem examination, left ventricle hypertrophy and idiopathic interstitial myocardial fibrosis was found. We believe that life-long, repetitive bouts of arduous physical activity resulted in fibrous replacement of the myocardium, causing a pathological substrate for the propagation of fatal arrhythmias.

This study reports the cardiac structure and function of a lifelong male endurance athlete, who has run over 148 000 miles, who presented with symptoms of chest discomfort, dyspnoea and loss of competitive running performance. Importantly, the athlete documented several periods of regular intensive endurance activity while suffering with flu-like symptoms. Cardiovascular MRI demonstrated a pattern of late gadolinium enhancement, which indicated myocardial scarring as a result of previous myocarditis.Myocarditis is a non-ischaemic inflammatory disease of the myocardium associated with cardiac dysfunction and arrhythmogenic substrate. The clinical course of viral myocarditis is mostly insidious with limited cardiac inflammation and dysfunction. However, as in the present case, overwhelming inflammation may occur in a subset of patients leading to myocardial fibrosis due to recurrent inflammation.