Impact of ethnicity upon cardiovascular adaptation in competitive athletes: relevance to preparticipation screening

Abstract

Regular participation in intensive physical exercise is associated with several structural and electrophysiological cardiac adaptations that enhance diastolic filling and facilitate a sustained increase in the cardiac output that is fundamental to athletic excellence. Such cardiac adaptations are collectively referred to as the ‘Athlete's Heart’ and are frequently reflected on the 12-lead ECG and imaging studies. Thorough knowledge relating to exercise-associated cardiovascular adaptation is imperative for the purposes of differentiating physiological adaptation from cardiac pathology, since an erroneous diagnosis of cardiac disease has potentially serious consequences for the athlete's physical, psychological, social and financial well-being. The majority of studies investigating the cardiovascular adaptation to exercise are based on cohorts of Caucasian athletes. However, there is mounting evidence that ethnicity is an important determinant of the objective manifestations of cardiovascular adaptation to exercise. The most pronounced paradigm of ethnically distinct cardiovascular adaptation to exercise stems from athletes of African/Afro-Caribbean descent, who exhibit a significantly higher prevalence of repolarisation anomalies and left ventricular hypertrophy, compared to Caucasian athletes; the differentiation between athlete's heart and hypertrophic cardiomyopathy is particularly challenging in this ethnic group. The extrapolation of ECG and echocardiographic criteria used to diagnose potentially serious cardiac disorders in Caucasian athletes to the African/Afro-Caribbean athlete population would result in an unacceptable number of unnecessary investigations and increased risk of false disqualification from competitive sport. Accurate interpretation of the athlete's ECG and echocardiogram is crucial, particularly when one considers the continuous expansion of preparticipation screening programmes. This review attempts to highlight ethnically determined differences in cardiovascular adaptation to exercise and provides a practical guide for the interpretation of baseline investigations in athletes of diverse ethnic backgrounds.

Systematic echocardiography is not efficacious when screening an ethnically diverse cohort of athletes in West Asia

“…The most pronounced paradigm of ethnically distinct modifications stems from athletes of African/Afro-Caribbean descent, who exhibit a significantly higher prevalence of repolarization anomalies and left ventricular hypertrophy (LVH), posing significant challenges when differentiating physiological LVH from HCM. 6,7 For 2 years, our insitution has followed the model of systematic ECHO when screening all high-level athletes competing in Qatar (an ethnically diverse and heterogenous population). Accordingly, we sought to: (1) confirm the efficacy of systemic ECHO alongside the ECG, personal/family history questionnaires, and physical examination, as collective tools to identify diseases with the potential to cause SCD within our population of athletes; and (2) provide a cost-analysis of a government-funded pre-participation screening programme.…”

Imaging focal and interstitial fibrosis with cardiovascular magnetic resonance in athletes with left ventricular hypertrophy: implications for sporting participation

“…The extremes of LVH seen in athletes (beyond 13 mm in men and 12 mm in women) overlap with that seen in patients with morphologically mild HCM 11. Thus, an athlete with LVH beyond 13 mm represents a grey zone between physiological adaptation and mild expression of HCM, although LVH of up to 16 mm has been shown in black athletes, which again highlights the difficulty of interpreting wall thickness measurements in making the distinction between pathology and athletic remodelling 12. Various criteria for making this distinction have been described, including the degree of LVH, patterns of LVH and left ventricular cavity size (table 2).…”

Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age)

“…6,117,[225][226][227][238][239][240][241][242] Notably, ethnic and racial differences are underscored by Magalski et al, 225 who found potentially pathological patterns in ECGs in 30% of black professional football players compared with only 13% of whites, a difference that was independently associated with race. T-wave inversions in anterior leads V 1 through V 4 have been cited as unique ethnic variants in the ECGs that occur in male athletes of African/Afro-Caribbean origin.…”

“…T-wave inversions in anterior leads V 1 through V 4 have been cited as unique ethnic variants in the ECGs that occur in male athletes of African/Afro-Caribbean origin. 239 241 Therefore, screening ECGs can be influenced by racial distribution, which can potentially inflate false-positive rates 89,225,227,[238][239][240][241][242] ; this resonates for African and other black athletes, in whom left ventricular wall thickness can exceed that of white athletes. 238,240 These factors could potentially trigger a cascade of unfortunate events that would generate an overdiagnosis of HCM, as well as unfair and unnecessary disqualification from competitive sports.…”