Di Gioia G; Institute of Sports Medicine and Science, Rome, Italy.
Ferrera A; Spera FR; Pelliccia A; Squeo MR

International Journal of Cardiology. 464:134785, 2026 Dec 01.

BACKGROUND: Low QRS voltage (LQRSV) is an uncommon electrocardiographic
finding in able-bodied athletes and it is investigated to exclude
underlying cardiomyopathy. Its prevalence and clinical meaning in
Paralympic athletes (PA), particularly those with spinal cord injury
(SCI), remain unknown.

OBJECTIVES: To describe the prevalence of LQRSV in elite PA and to
explore its associations with cardiac structure and functional parameters,
with attention to differences between athletes with and without SCI.

METHODS: 193 healthy Olympic PA underwent anthropometric assessment,
12-lead-ECG, comprehensive echocardiography, and cardiopulmonary exercise
testing. Athletes were classified according to disability (SCI vs.
non-SCI). LQRSV was defined according to international criteria.

RESULTS: PA had mean age 32.7 +/- 9.7 years, and 44% were females. LQRSV
was identified in 22 athletes (11.4%), with a higher prevalence among
those with SCI (27.6% vs. 4.6% in NSCI, p < 0.0001). Athletes with LQRSV
were older (p = 0.01), frequently involved in skill-based sports (p <
0.0001). Compared with athletes with normal ECG voltages, they exhibited
reduced exercise performance (VO2 max 23.1 +/- 10.5 vs. 37 +/- 14.5
mL/min/kg; p < 0.0001) and lower O2 pulse (p < 0.0001). Echocardiography
revealed smaller left ventricular (LV) volumes and LV mass, while systolic
function was preserved (p = 0.488). Among SCI athletes, those with LQRSV
demonstrated lower W/kg (p = 0.039), lower LV mass (p = 0.037) and higher
fat mass (p = 0.035). At multivariable logistic regression analysis, SCI
emerged as the only independent correlate of LQRSV (p = 0.011).

CONCLUSIONS: LQRSV shows an unexpectedly high prevalence in PA,
particularly those with SCI, and may reflect a cardiac phenotype
characterized by smaller chambers and reduced metabolic drive, rather than
pathological remodeling.