The diagnostic value of including an exercise session during 24-h ambulatory ECG monitoring in athletes

Introduction In athletes undergoing pre-participation screening (PPS), ambulatory ECG monitoring is often prescribed in cases of arrhythmias at baseline or suspicious symptoms. Since performing an exercise session during 12‑leads 24-h ambulatory ECG monitoring (24 h-ECG) is recommended but not supported by evidence, this study aimed to evaluate whether the inclusion of exercise sessions enhances the detection of high-risk cardiovascular diseases (CVD). Methods This study analysed 4315 athletes who underwent PPS with exercise stress testing (EST) at our centre and who, due to abnormal findings, were referred for second-line investigations, including 24 h-ECG with an exercise session. Athletes were categorised according to the presence and exercise-relation of premature ventricular beats (PVBs) on 24 h-ECG. Third-line assessments were prescribed in selected cases. Results 235 athletes were included in the study: 154 (66 %) athletes showed <10 PVBs, 22 exercise-suppressed PVBs, 23 with PVBs that occurred during both rest and exercise, 36 exercise-induced PVBs. 13 athletes were identified with high-risk CVD: 4/176 (2.3 %) among those with no or exercise-suppressed PVBs versus 9/59 (15 %, p < 0.001) among those with exercise-persistent or exercise-induced PVBs. Among the 26 athletes with PVBs during both peak exercise on EST and 24 h-ECG, 7 (27 %) were diagnosed with high-risk CVD, compared to 6 (2.9 %, p < 0.001) of the remaining 209 athletes. Conclusions Incorporating an exercise session into 24 h-ECG improves the detection of arrhythmic patterns potentially associated with high-risk CVD. The risk was particularly high when exercise-induced PVBs were observed during both EST and 24 h-ECG. These findings support the implementation of exercise-inclusive 24 h-ECG protocols in sports cardiology.