Sex differences and physical activity associations with electrocardiographic patterns in amateur athletes: a cross-sectional study
DOI:
https://doi.org/10.47197/retos.v71.117255Keywords:
amateur athletes, electrocardiogram, gender differences, physical activity, sports cardiologyAbstract
Introduction: The increase in sudden death cases among Moroccan amateur athletes highlights the importance of thorough medical examinations including electrocardiograms.
Objective: This cross-sectional study aimed to identify the frequency of ECG findings in Moroccan amateur athletes, examine sex disparities, and assess how physical activity levels affect cardiac electrical patterns.
Methodology: The study included 149 amateur athletes (70 men, 79 women) from the University Hassan 1st in Settat. Participants underwent 12-lead ECG, anthropometric measurements, and physical activity assessment using the International Physical Activity Questionnaire - Short Form. Results: Male athletes showed significantly higher rates of sinus bradycardia (41.4% vs 12.7%) and ST-segment elevation (41.4% vs 0%) than female athletes (p<.0001). High levels of physical activity were significantly associated with training-related ECG changes (p=.010) and ST-segment elevation (p=.027).
Discussion: These findings emphasize the importance of considering physical activity levels when interpreting ECG patterns in amateur athletes and highlight significant sex differences in cardiac adaptations.
Conclusions: Sex-specific ECG interpretation guidelines are needed for amateur athletes, with particular attention to training-related adaptations in males and the relationship between physical activity intensity and cardiac electrical patterns.
References
Abu Bakar, N. A., Luqman, N., Shaaban, E., & Abdul Rahman, H. (2018). Prevalence and predictors of electrocardiogram abnormalities among athletes. Asian Cardiovascular and Thoracic Annals, 26(8), 603–607. https://doi.org/10.1177/0218492318807533
Afaghi, S., Rahimi, F. S., Soltani, P., Kiani, A., & Abedini, A. (2024). Sex‐Specific Differences in Cardio-vascular Adaptations and Risks in Elite Athletes: Bridging the Gap in Sports Cardiology. Clinical Cardiology, 47(9). https://doi.org/10.1002/clc.70006
Arbab-Zadeh, A., Perhonen, M., Howden, E., Peshock, R. M., Zhang, R., Adams-Huet, B., Haykowsky, M. J., & Levine, B. D. (2014). Cardiac Remodeling in Response to 1 Year of Intensive Endurance Training. Circulation, 130(24), 2152–2161. https://doi.org/10.1161/circulationaha.114.010775
Ben Rakaa, O., Bassiri, M., & Lotfi, S. (2024). Epidemiological Study of The Physical Ability to Practice Physical Education in Children with School Pathologies. Journal of Biostatistics and Epidemiol-ogy. https://doi.org/10.18502/jbe.v10i4.18522
Ben Rakaa, O., Bassiri, M., & Lotfi, S. (2025). Impact of adapted physical education and para-athletics on mental skills and on pedagogical and school inclusion of teenagers with disabilities. Retos, 68, 82–94. https://doi.org/10.47197/retos.v68.111520
Bianco, M., Zeppilli, P. (2022). Electrocardiographic Changes in the Athlete’s Heart. In: Delise, P., Zep-pilli, P. (eds) Sport-related sudden cardiac death. Springer, Cham. https://doi.org/10.1007/978-3-030-80447-3_2
Borkytė, J., & Žumbakytė-Šermukšnienė, R. (2018). TRANSTHORACIC ECHOCARDIOGRAPHY AND DE-PENDENCE OF ELECTROCARDIOGRAPHIC INDICATORS ON PHYSICAL ACTIVITY TYPE IN LITHUANIAN ATHLETES. Baltic Journal of Sport and Health Sciences, 2(109), 9–14. https://doi.org/10.33607/bjshs.v2i109.191
Bouzid, W., Ben Rakaa, O., Chokri, A., Eloirdi, A., Elhaboussi, A., & Barkaoui, M. (2025). Effect of an 8-week training program on the rebalancing of functional asymmetry in young footballers. Retos, 70, 1422–1437. https://doi.org/10.47197/retos.v70.117056
Ceornodolea, A. D., Bal, R., & Severens, J. L. (2017). Epidemiology and Management of Atrial Fibrilla-tion and Stroke: Review of Data from Four European Countries. Stroke Research and Treat-ment, 2017, 1–12. https://doi.org/10.1155/2017/8593207
Churchill, T. W., Petek, B. J., Wasfy, M. M., Guseh, J. S., Weiner, R. B., Singh, T. K., Schmied, C., O’Malley, H., Chiampas, G., & Baggish, A. L. (2021). Cardiac Structure and Function in Elite Female and Male Soccer Players. JAMA Cardiology, 6(3), 316. https://doi.org/10.1001/jamacardio.2020.6088
Climstein, M., Graham, K. S., Stapelberg, M., Walsh, J., DeBeliso, M., Adams, K., Sevene, T., & Harris, C. (2025). Electrocardiographic Assessment of National-Level Triathletes: Sinus Bradycardia and Other Electrocardiographic Abnormalities. Sports, 13(1), 25. https://doi.org/10.3390/sports13010025
CORÎCI, O. M., & MIREA-MUNTEANU, O. (2018). Gender-Related Electrocardiographic Changes in Ath-letes. Current Health Sciences Journal, 1, 29–33. https://doi.org/10.12865/CHSJ.44.01.05
Cotrim, C., Palinkas, E. D., & Cotrim, N. (2023). The Importance of Left Ventricular Outflow Tract and Mid-Ventricular Gradients in Stress Echocardiography: A Narrative Review. Journal of Clinical Medicine, 12(16), 5292. https://doi.org/10.3390/jcm12165292
Craig, C. L., Marshall, A. L., Sjöström, M., Bauman, A. E., Booth, M. L., Ainsworth, B. E., Pratt, M., Ekelund, U., Yngve, A., Sallis, J. F., & Oja, P. (2003). International Physical Activity Question-naire: 12-Country Reliability and Validity: Medicine & Science in Sports & Exercise, 35(8), 1381–1395. https://doi.org/10.1249/01.MSS.0000078924.61453.FB
Delise, P., & Zeppilli, P. (Eds.). (2022). Sport-related sudden cardiac death: Causes and prevention. Springer International Publishing. https://doi.org/10.1007/978-3-030-80447-3
Dores, H., Malhotra, A., Sheikh, N., Millar, L., Dhutia, H., Narain, R., Merghani, A., Papadakis, M., & Sharma, S. (2016). Abnormal electrocardiographic findings in athletes: Correlation with inten-sity of sport and level of competition. Revista Portuguesa de Cardiologia (English Edition), 35(11), 593–600. https://doi.org/10.1016/j.repce.2016.10.014
Dinger, M. K., Behrens, T. K., & Han, J. L. (2006). Validity and Reliability of the International Physical Activity Questionnaire in College Students. American Journal of Health Education, 37(6), 337–343. https://doi.org/10.1080/19325037.2006.10598924
Drezner, J. A., Sharma, S., Baggish, A., Papadakis, M., Wilson, M. G., Prutkin, J. M., Gerche, A. L., Acker-man, M. J., Borjesson, M., Salerno, J. C., Asif, I. M., Owens, D. S., Chung, E. H., Emery, M. S., Fro-elicher, V. F., Heidbuchel, H., Adamuz, C., Asplund, C. A., Cohen, G., … Corrado, D. (2017). Inter-national criteria for electrocardiographic interpretation in athletes: Consensus statement. Brit-ish Journal of Sports Medicine, 51(9), 704–731. https://doi.org/10.1136/bjsports-2016-097331
Fanale, V., Segreti, A., Fossati, C., Di Gioia, G., Coletti, F., Crispino, S. P., Picarelli, F., Antonelli Incalzi, R., Papalia, R., Pigozzi, F., & Grigioni, F. (2024). Athlete’s ECG Made Easy: A Practical Guide to Sur-viving Everyday Clinical Practice. Journal of Cardiovascular Development and Disease, 11(10), 303. https://doi.org/10.3390/jcdd11100303
George, K., Whyte, G. P., Green, D. J., Oxborough, D., Shave, R. E., Gaze, D., & Somauroo, J. (2012). The endurance athlete’s heart: Acute stress and chronic adaptation. British Journal of Sports Medi-cine, 46(Suppl 1), i29–i36. https://doi.org/10.1136/bjsports-2012-091141
Güllich, A., Barth, M., Macnamara, B. N., & Hambrick, D. Z. (2023). Quantifying the Extent to Which Suc-cessful Juniors and Successful Seniors are Two Disparate Populations: A Systematic Review and Synthesis of Findings. Sports Medicine, 53(6), 1201–1217. https://doi.org/10.1007/s40279-023-01840-1
Hądzlik, I., Piotrowski, J., Biały-Karbowniczek, J., Słychan, K., Jędrasek, A., Bulska, K., Jędrasek, T., Łuczak, B., Pogoda, J., & Sławek, K. (2024). Balancing Cardiovascular Health: Assessing the Im-pact of Physical Activity on Athletic Cardiac Adaptations and Cardiac Pathology. Quality in Sport, 18, 53460. https://doi.org/10.12775/qs.2024.18.53460
Hoi Lun (Helen) Cheng. (2016). A simple, easy-to-use spreadsheet for automatic scoring of the Interna-tional Physical Activity Questionnaire (IPAQ) Short Form [Dataset]. Unpublished. https://doi.org/10.13140/RG.2.2.21067.80165
Hostrup, M., & Bangsbo, J. (2023). Performance Adaptations to Intensified Training in Top-Level Foot-ball. Sports Medicine, 53(3), 577–594. https://doi.org/10.1007/s40279-022-01791-z
Kaleta, A. M., Lewicka, E., Dąbrowska-Kugacka, A., Lewicka-Potocka, Z., Wabich, E., Szerszyńska, A., Dyda, J., Sobolewski, J., Koenner, J., & Raczak, G. (2018). Electrocardiographic abnormalities in amateur male marathon runners. Advances in Clinical and Experimental Medicine, 27(8), 1091–1098. https://doi.org/10.17219/acem/73700
Kolenda Zloić, S., & Hrabak‐Paar, M. (2024). The Role of Cardiac Magnetic Resonance Imaging in Dis-tinguishing the Athlete’s Heart From Hypertrophic Cardiomyopathy–A Brief Literature Review. Echocardiography, 41(11). https://doi.org/10.1111/echo.70021
Lasocka-Koriat, Z., Lewicka-Potocka, Z., Kaleta-Duss, A., Siekierzycka, A., Kalinowski, L., Lewicka, E., & Dąbrowska-Kugacka, A. (2024). Differences in cardiac adaptation to exercise in male and fe-male athletes assessed by noninvasive techniques: A state-of-the-art review. American Journal of Physiology-Heart and Circulatory Physiology, 326(5), H1065–H1079. https://doi.org/10.1152/ajpheart.00756.2023
Lee, P. H., Macfarlane, D. J., Lam, T., & Stewart, S. M. (2011). Validity of the international physical activ-ity questionnaire short form (IPAQ-SF): A systematic review. International Journal of Behav-ioral Nutrition and Physical Activity, 8(1). https://doi.org/10.1186/1479-5868-8-115
Malhotra, A., Dhutia, H., Yeo, T.-J., Finocchiaro, G., Gati, S., Bulleros, P., Fanton, Z., Papatheodorou, E., Miles, C., Keteepe-Arachi, T., Basu, J., Parry-Williams, G., Prakash, K., Gray, B., D’Silva, A., En-sam, B., Behr, E., Tome, M., Papadakis, M., & Sharma, S. (2020). Accuracy of the 2017 interna-tional recommendations for clinicians who interpret adolescent athletes’ ECGs: A cohort study of 11 168 British white and black soccer players. British Journal of Sports Medicine, 54(12), 739–745. https://doi.org/10.1136/bjsports-2017-098528
Malmgren, A., Trägårdh, E., Gudmundsson, P., Kjellström, B., Stagmo, M., & Dencker, M. (2024). Elec-trocardiographic manifestations in female team handball players: Analyzing ECG changes in athletes. Frontiers in Sports and Active Living, 6. https://doi.org/10.3389/fspor.2024.1384483
Petek, B. J., Drezner, J. A., & Churchill, T. W. (2023). The International Criteria for Electrocardiogram Interpretation in Athletes. Cardiology Clinics, 41(1), 35–49. https://doi.org/10.1016/j.ccl.2022.08.003
Pittaras, A., Faselis, C., Doumas, M., Grassos, C., & Kokkinos, P. (2023). Physical Activity and Cardiac Morphologic Adaptations. Reviews in Cardiovascular Medicine, 24(5). https://doi.org/10.31083/j.rcm2405142
Roberts-Lewis, S. F., White, C. M., Ashworth, M., & Rose, M. R. (2022). The validity of the International Physical Activity Questionnaire (IPAQ) for adults with progressive muscle diseases. Disability and Rehabilitation, 44(23), 7312–7320. https://doi.org/10.1080/09638288.2021.1983042
Rojas-Valencia, J. T., Higuera-Dagovett, E., Vega Llamas, R., Prieto Mondragón, L. D. P., Buitrago Espit-ia, J. E., & Rodríguez Buitrago, J. A. (2024). Electrocardiographic findings in a group of physical-ly active young adults who reside at 2,600 meters above the sea level: An exploratory study. Retos, 59, 577–583. https://doi.org/10.47197/retos.v59.103145
Sharma, S., Whyte, G., Elliott, P., Padula, M., Kaushal, R., Mahon, N., & McKenna, W. J. (1999). Electro-cardiographic changes in 1000 highly trained junior elite athletes. British Journal of Sports Medicine, 33(5), 319–324. https://doi.org/10.1136/bjsm.33.5.319
Sokunbi, O. J., Okoromah, C. A. N., Ekure, E. N., Olawale, O. A., & Eke, W. S. (2021). Electrocardiograph-ic pattern of apparently healthy African adolescent athletes in Nigeria. BMC Pediatrics, 21(1). https://doi.org/10.1186/s12887-021-02557-8
Stein, R., Ferrari, F., Da Silveira, A. D., Rossi, A. P., Pedrotti, L. G., Dilda, G. D., Aleixo, H. C., Magalhaes, F. C. O., Emed, L. G. M., Soares, L. G., Alo, R. O. B., Ritt, L. E. F., Braga, F., Herdy, A. H., & Froelicher, V. F. (2025). Distinct early repolarization patterns in male brazilian football play-ers: Insights from a multicenter study. European Journal of Preventive Cardiology, 32(Supplement_1). https://doi.org/10.1093/eurjpc/zwaf236.422
Tebar, W. R., Ritti-Dias, R. M., Mota, J., Farah, B. Q., Saraiva, B. T. C., Damato, T. M. M., Delfino, L. D., Aguilar, B. A. S., Dos Santos, A. B., Silva, S. C. B., Vanderlei, L. C. M., & Christofaro, D. G. D. (2020). Relationship between domains of physical activity and cardiac autonomic modulation in adults: A cross-sectional study. Scientific Reports, 10(1). https://doi.org/10.1038/s41598-020-72663-7
Tougouma, S. J.-B., Yaméogo, N. V., Kambiré, Y., Yaméogo, A. A., Sidibé, S., Kologo, J. K., Millogo, G., Ouédraogo, S., Bamouni, J., & Zabsonré, P. (2019). Electrocardiography of a Top Athlete in Bo-bo-Dioulasso, Burkina Faso. World Journal of Cardiovascular Diseases, 09(07), 449–457. https://doi.org/10.4236/wjcd.2019.97040
Tremamunno, S., & Lanza, G. A. (2023). Is Early Repolarization Syndrome a Risk for Sudden Cardiac Death in Young Athletes? Current Treatment Options in Cardiovascular Medicine, 25(10), 561–571. https://doi.org/10.1007/s11936-023-01007-1
Wen, X., Huang, Y., Shen, T.-H., Gong, Y.-L., Dong, R., Xia, L., & Xie, T. (2021). Prevalence of abnormal and borderline electrocardiogram changes in 13, 079 Chinese amateur marathon runners. BMC Sports Science, Medicine and Rehabilitation, 13(1). https://doi.org/10.1186/s13102-021-00268-2
Zorzi, A., Vio, R., Bettella, N., & Corrado, D. (2020). Criteria for interpretation of the athlete’s ECG: A critical appraisal. Pacing and Clinical Electrophysiology, 43(8), 882–890. https://doi.org/10.1111/pace.14001
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Copyright (c) 2025 Younes Brouki, Youssef El Machrouh, Chaimae Khali, Mohamed Barkaoui, Aziz Eloirdi, Boujemaa Zahi, Aziz Chokri

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