CardioPulse
doi:10.1093/eurheartj/ehz559
Occupational Cardiology IV
ECG interpretation
Interpretation of the ECG in young, fit, asymptomatic individuals undertaking
high-hazard occupations is the topic of the fourth article in the occupational
cardiology series
An electrocardiogram (ECG) is a well-tolerated, non-invasive, and inex-
pensive test for overt electrical signs of cardiac pathology, including
conduction disease, accessory pathways, and channelopathies; struc-
tural heart disease and previous ischaemic injury. Resting ECGs are
widely used in screening of individuals applying for, or engaged in, high-
hazard employment to exclude cardiac conditions incompatible with
high-risk work. The use of screening ECGs is commonplace in law-
enforcement, commercial diving operations, offshore working, and avi-
ation. In an asymptomatic, often young and fit population, there are sev-
eral considerations for the accurate interpretation of ECG findings.
False negatives
A ‘normal’ resting 12-lead ECG may represent a false negative finding:
a. where cardiac pathology doesn’t cause an abnormal ECG, as aortic
root dilatation, premature coronary artery disease (CAD), and anoma-
lous coronary anatomy1;
b. where an inherited cardiac condition phenotype has not developed
sufficiently that the surface ECG is abnormal, e.g. early arrhythmogenic
right ventricular cardiomyopathy;
c. where ECG abnormalities are intermittent or only seen with provoca-
tion, such as borderline-prolonged corrected QT interval (QTc) or
Brugada pattern ECG; and
d. where ECG abnormalities are not evident at rest, e.g. rate-related left
bundle branch block (LBBB).
False positives
In routine occupational ECG screening of young, fit individuals it is the
interpretation of an ‘abnormal’ ECG which presents the greatest
challenge:
a. Bayesian inference predicts that the probability of disease underlying
an ‘abnormal’ finding on a standard 12-lead ECG in an asymptomatic,
young person, with no cardiovascular history (i.e. with low pre-test
probability of disease) is much lower than the same ‘abnormality’ in a
higher risk individual; such as a 60-year-old smoker with exertional
breathlessness and palpitations;
b. The parameters of the 12-lead ECG are subject to variation and will
tend to follow a Normal (Gaussian) distribution or, for some parame-
ters, a skewed distribution e.g. QRS duration. The historical upper limit
cut-off Bazett’s QTc of 450 ms (men) and 460 ms (women) represents
the 95th centile of the QT interval. In an ECG screening program,
which analyses 10 000 ECGs annually, 2.5%, or 250 people will have a
QTc longer than this ‘normal’ limit. Even with an updated upper QTc
2663
Downloaded from https://academic.oup.com/eurheartj/article-abstract/40/32/2663/5552595 by guest on 02 January 2020
limit of 470 ms (Ref. 2)/480 ms (Ref. 3), there will be a significant minor-
ity who trigger as ‘abnormal’ though they represent the upper zone of
the ‘normal’ range;
c. certain changes may result from appropriate cardiac adaptation to
exercise training. Such adaptations lead to a series of ‘normal variants’
which require their own careful treatment by a screening cardiologist.
‘Normal’ variants
The consensus on what constitutes a ‘normal’ ECG variant is not fixed.
Early ventricular repolarization was once considered a normal finding
in healthy young adults; we now know that inferior and inferolateral
distribution of early repolarization, at least when combined with
planar/down-sloping ST segment morphology, is associated with an
increased risk of idiopathic ventricular fibrillation.4 In part, this appa-
rent change reflects a reclassification of the original description of early
repolarization, which included both J-point elevation (high take off)
and rapidly ascending, elevated ST morphology.
Another example of a change in understanding is premature atrial
contractions (PACs) and short runs of atrial ectopy. Historically
regarded as benign, these ECG findings are increasingly recognized as
markers for future development of atrial fibrillation and, independent
of AF, predictors of stroke risk. In a 15-year follow-up study of men
and women age 55–75, without a history of stroke, AF, or cardiovascu-
lar disease, 15% met the ‘excessive atrial ectopy’ criteria (30 PACs/h
or atrial ectopic run 20 beats during 48-h Holter). Among this 15%,
the hazard ratio for stroke was 1.96 and, for those with a
CHA2DS2-VASc of 2, the annual stroke risk was 2.4%, similar to
that for AF.5 Though the significance of a lower burden of atrial
ectopy is not known, it is interesting that in Hiss’ 1962 study of
122 000 USAF aircrew the prevalence of atrial ectopy on 12-lead
ECG was 0.4%.6
It is generally accepted that the presence of ‘occasional’ premature
ventricular complexes (PVCs) is a normal finding. However, it is now
clear that there is a ‘burden-related’ association with left ventricular
(LV) dysfunction (which can occur with PVC burden 10% or more)
and mortality. Using a definition of ‘frequent’ ventricular ectopy of 1
PVC per standard 12-lead ECG or 30 PVCs per hour (8% burden)
a recent meta-analysis (>100 000 asymptomatic participants with no
cardiac history) found that the hazard ratio for sudden cardiac death
was 2.64.7
An important subgroup of ECG variants is seen in elite athletes. It is
not certain what volume of exercise training may be expected to
change the resting ECG. Sharma et al.2 suggest that 4 h per week of
2664
Figure 1 Electrocardiogram screening tool for use with athletes’ screening electrocardiograms.2 International consensus standards for electrocar-
diographic interpretation of athletes. AV, atrioventricular block; LBBB, left bundle branch block; LVH, left ventricular hypertrophy; RBBB, right bundle
branch block; RVH, right ventricular hypertrophy; PVC, premature ventricular contraction; SCD, sudden cardiac death.
intensive exercise training will result in some of the typical athlete find-
ings. Certainly, not all workers in the high-hazard professions will
undertake this exercise volume. However, the activity of cohorts
engaged in military aviation, law-enforcement, and firefighting will
result in considerable overlap between ‘athlete’ and ‘worker’ groups.
Therefore practical guidance from sports cardiology (Figure 1)2 may be
helpful in interpreting ECG variants which are thought to result from
the cardiac chamber dilatation, muscular hypertrophy and increased
Vagal tone, which result from exercise training. Indeed, a recent table
of suggested normal/borderline/abnormal ECG findings appropriate to
aviation are similar.8 However, a careful history regarding the volume
of physical training is necessary to avoid misclassifying an ECG abnor-
mality as ‘athletic adaptation’; such as misinterpreting LV hypertrophy
by voltage criteria as an athletic adaptation in a relatively sedentary
individual with cardiomyopathy.
Military studies have shown that the vagally mediated rhythms
described in athletes are seen in service personnel. The ECGs of 122
000 US Airforce aircrew, age 16–50, collected 1957–62, demonstrated
an ectopic atrial rhythm in 0.6% overall, but in the youngest cohort
(16–19) the prevalence was 1.5%.6 Vagally mediated nocturnal, sec-
ond-degree Mobitz I heart block is commonly detected in asympto-
matic military aviators undergoing Holter ECG. These individuals
invariably have a normal conduction response to exercise stress.
Given the potential hypoxia of both high-altitude work and aviation, it
is striking that an implantable loop recorder study of fit, asymptomatic
military mountaineers in the Himalayas demonstrated that 50% of the
CardioPulse
Downloaded from https://academic.oup.com/eurheartj/article-abstract/40/32/2663/5552595 by guest on 02 January 2020
group experienced at least one nocturnal pause of 3–7 s and one indi-
vidual experienced nocturnal, vagally mediated AF.9
Exercise electrocardiogram
There is no role for exercise ECG testing in ‘occupational screening’
for CAD in a young, asymptomatic population with very low pre-test
probability. The false positive rate would be unacceptably high.
However, the exercise ECG does have a useful role in the diagnosis of
rate-related LBBB, or other conduction disease; in risk stratification—
looking for suppression of ventricular ectopy, or shortening of QTc on
exertion, or examining the QTc at 4 min of recovery post-exercise;
and in ‘enhanced cardiovascular assessment’ of older workers (particu-
larly men) in whom the pre-test probability of CAD is higher, and in
whom it is necessary to have the prognostic reassurance of completing
9 min of the Bruce protocol.10
Appropriate use of the
electrocardiogram and schedule
for periodic electrocardiogram
investigation
The utility of ECG screening of workers in high-hazard groups is that
the ECG may detect occult cardiac disease. This occurs in a bimodal
CardioPulse 2665

Aviaon
European Aviaon (Class 1)

Military Aviaon (UK)

Diving
Military Diving (UK)

Downloaded from https://academic.oup.com/eurheartj/article-abstract/40/32/2663/5552595 by guest on 02 January 2020

Commercial Diving (UK)- As clinically indicated

Age
(years)
Inial 20 30 40 50 60
Commercial Driving
European Commercial Driving
Stress ECG age 45, otherwise as clinically indicated
Commercial Driving (UK)
As clinically indicated

Offshore Energy
As clinically indicated

Brish Antarcc Survey (Remote working in polar environment)

12 lead ECG age 50, otherwise as clinically indicated

Legend 12 lead electrocardiogram Exercise electrocardiogram

Figure 2 ECG schedules in high-hazard professions.

age-distribution. Screening at entry is intended to detect undiagnosed
inherited cardiac conditions. There is evidence that this is effective
from sports cardiology experience. A meta-analysis of 47 000 ath-
letes demonstrated that screening ECG was 5 times more sensitive
than the history and 10 times more sensitive than the physical exam.11
Although the false positive rate of the ECG was 6%, this was lower
than for either history or exam. In spite of this, there has been only
one study in sports cardiology, which demonstrated a survival benefit
of ECG screening.12
As workers age, the predominant focus of cardiovascular disease
detection shifts to CAD. Coronary artery disease may be detected at
rest through associated conduction disease, arrhythmia burden, or
even evidence of missed infarction; or due to changes on exercise
ECG testing (with limited accuracy), as part of age-related ‘enhanced
cardiovascular screening’ by ischaemic symptoms, ECG changes, or
exertional intolerance/inadequate blood pressure response. This
bimodal focus of attention is reflected in the ECG schedules of the
high-hazard professions (Figure 2). Typically, these comprise an ECG at
entry, and very infrequent, if any, repeat ECGs until middle age, with
progressively frequent testing, and increased use of treadmill ECGs, as
the risk of coronary disease rises.
Improving the management of an
asymptomatic electrocardiogram
abnormality
Currently, interpretation of positive, or ‘normal’ variant ECG findings
in asymptomatic young workers is almost entirely based on expert
consensus. The Copenhagen Holter Study demonstrates the huge clin-
ical potential of interval follow-up of carefully characterized ECG find-
ings in an asymptomatic group.5
This paradigm offers both a path, and a challenge, to cardiologists
with responsibility for high-hazard groups: to store, analyse, and char-
acterize the baseline ECG findings of those they screen and to follow
2666 CardioPulse

them up aggressively, in order to determine the true associations and Conflict of interest: none declared.
to distinguish the genuine normal from the as-yet undiscovered
markers of future cardiac disease.
Rebecca R. CHAMLEY, MB BS, BSc
Cardiology Trainee
Oxford Heart Centre
Oxford University Hospital NHS Foundation Trust
UK
Tel: +44 1865 234573
Email: rebecca.chamley@nhs.net

David A. Holdsworth MA DPhil Kim RAJAPPAN, MD, FRCP Edward D Nicol, MD FRCP FRCR FESC FACC DAvMed

Downloaded from https://academic.oup.com/eurheartj/article-abstract/40/32/2663/5552595 by guest on 02 January 2020

Consultant Cardiologist
Oxford Heart Centre
John Radcliffe Hospital
Oxford, UK
Tel: +44 1865 223160
Email: david.holdsworth@nhs.net
Consultant Cardiologist & Electrophysiologist Consultant Cardiologist
Cardiac Department Aviation Medicine Clinical Service
John Radcliffe Hospital Centre of Aviation Medicine
RAF Henlow
Oxford University Hospitals NHS Foundation Trust
Oxford, OX3 9DU, UK Beds., SG16 6DN, UK
Tel: + 44 1865 223172 Tel: +44 1462 851515 ext. 6353
Email: kim.rajappan@ouh.nhs.uk Email: e.nicol@nhs.net

doi:10.1093/eurheartj/ehz576

The GREATresearch network

A network that places young physician research scientists first, had its 12th annual
meeting in the legendary Edinburgh Castle in Scotland

Addressing the major unmet need of interdisciplinary international dedicated to presentations by young researchers. Moreover, the
clinical research in acute conditions, the GREAT research network atmosphere of the meeting from the beginning is highly supportive and
was founded 12 years ago by Professor Alexandre Mebazaa (Paris), encouraging for young researchers in order to allow them to grow and
Professor Salvatore Di Somma (Rome), and Professor Christian Müller become confident in the presentation and discussion of science.
(Basel). While initially focused on the diagnosis and management of
patients with acute heart failure, the research topics of the GREAT
research network have meanwhile expanded to include the diagnosis
and management of patients with acute myocardial infarction, syncope,
sepsis, and acute abdominal pain.

In addition, the meeting aims to foster personal relationships and

The GREAT research network combines academic research groups
from more than 30 countries and has a rotating annual meeting putting
young researchers first. More than half the time of the meeting is
even friendships if possible among the research groups in order to
establish trust and a collaborative spirit, that ultimately allows the
research groups to effectively join forces by combining existing data-
sets and collaborating in joined prospective studies that could never
ever have been managed by an individual research group.
‘And fun must definitely be part of the game’, explains Salvatore di
Somma. Therefore, the extensive social program also includes a foot-
ball match with the host country playing against the rest of the world.
‘Playing together in a football team has much in common with working
together in a research team’, adds Christian Mueller: ‘everybody has to
bring her/his talent and best efforts, and everybody has to support the
other team member wherever possible’.