Sex-associated Differences In Low QRS Voltage In Young Athletes

PURPOSE: Low QRS peak-to-nadir voltage (LQRSV) is associated with arrhythmogenic right ventricular cardiomyopathy (ARVC). Recent studies have proposed criteria for LQRSV when screening athletes for cardiovascular disease. These criteria have not yet been evaluated in a large population of healthy young athletes. METHODS: 10,728 (42.5% female, 57.5% male, mean age 18.1 ± 4.3 years) athletes who participated in mass ECG screenings between 2014-2021 at multiple sites across the United States including grade schools (11%), high schools (32%), colleges (50%), and professional athletic teams (7%) were included in a digital ECG dataset. Including only ECGs from initial evaluation among athletes 14-35 years of age and excluding those with right bundle branch block, left bundle branch block, Wolf-Parkinson-White pattern, and reversed leads, 8,679 (58% males, 42% females) remained eligible for analysis. QRS voltage was analyzed for each ECG lead and LQRSV criteria were applied. Results were stratified by sex. RESULTS: QRS voltage was significantly lower in all leads in females than in males (Figure). Mean limb lead voltage was 0.131 mV lower in females (p < 0.001) and mean precordial lead voltage was 0.721 mV lower in females (P < 0.001). LQRSV by limb lead criteria (<0.5 mV in all leads) was present in 0.47% of females and 0.41% of males (P = 0.7). LQRSV by pre-cordial lead criteria (<1.0 mV in all leads) was present in 1.08% of females and 0.00% of males (P < 0.001). 10.3% of females and 1.83% of males (P < 0.001) met the Sokolow-Lyon index for LQRSV (maximum R amplitude in V5/V6 + S amplitude in V1 < 1.5 mV). CONCLUSIONS: LQRSV is more common among female athletes than male athletes using established criteria. Using 1st percentile sex-specific cut points may yield more reasonable screening results. Sex-associated differences should be considered for any proposed novel LQRSV criteria in young athletes.