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  • Review Article
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Impact of ethnicity on cardiac adaptation to exercise

Nature Reviews Cardiology volume 11, pages 198–217 (2014)Cite this article

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A Correction to this article was published on 05 August 2014

This article has been updated

Key Points

  • Ethnicity is an important determinant of cardiovascular adaptation to exercise and should be considered during interpretation of the electrocardiogram and echocardiogram in athletes

  • Athletes of African or Afro-Caribbean ethnicity (black athletes) reveal profound electrical and structural alterations in response to exercise; 23% exhibit T-wave inversion and 13% left ventricular hypertrophy

  • Application of current electrocardiographic interpretation criteria derived from white athletes would result in >40% of black athletes being diagnosed with an abnormal electrocardiogram

  • In the absence of symptoms or family history of cardiomyopathy, T-wave inversion confined to leads V1–V4 is likely to represent an ethnically determined, physiological response to exercise in black athletes

  • Middle-Eastern athletes seem to exhibit similar electrical and structural changes in response to exercise as white athletes

  • More data are required for athletes from East and South Asia before conclusions can be made regarding cardiac adaptation to exercise in these ethnicities

Abstract

The increasing globalization of sport has resulted in athletes from a wide range of ethnicities emerging onto the world stage. Fuelled by the untimely death of a number of young professional athletes, data generated from the parallel increase in preparticipation cardiovascular evaluation has indicated that ethnicity has a substantial influence on cardiac adaptation to exercise. From this perspective, the group most intensively studied comprises athletes of African or Afro-Caribbean ethnicity (black athletes), an ever-increasing number of whom are competing at the highest levels of sport and who often exhibit profound electrical and structural cardiac changes in response to exercise. Data on other ethnic cohorts are emerging, but remain incomplete. This Review describes our current knowledge on the impact of ethnicity on cardiac adaptation to exercise, starting with white athletes in whom the physiological electrical and structural changes—collectively termed the 'athlete's heart'—were first described. Discussion of the differences in the cardiac changes between ethnicities, with a focus on black athletes, and of the challenges that these variations can produce for the evaluating physician is also provided. The impact of ethnically mediated changes on preparticipation cardiovascular evaluation is highlighted, particularly with respect to false positive results, and potential genetic mechanisms underlying racial differences in cardiac adaptation to exercise are described.

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Figure 1
Figure 2: Common, training-related electrocardiographic changes in athletes that do not warrant further investigation.
Figure 3: Electrocardiographic changes in athletes, which are unrelated to training and require further investigation.
Figure 4: Distributions of LV dimensions.
Figure 5: The spectrum of electrocardiographic patterns observed in black athletes.
Figure 6: Prevalence of electrocardiographic changes in black athletes, black controls, and black patients with HCM.
Figure 7: Prevalence of abnormal electrocardiographic patterns other than T-wave inversions in a large cohort of adult black (n = 904) or white (n = 1,819) elite athletes undergoing preparticipation evaluation.122
Figure 8: Distribution of LV wall thicknesses, illustrating the extent of the differences in LV hypertrophy between the ethnicities.
Figure 9: Distribution of values for parasternal short-axis proximal RVOT1 in 675 athletes.
Figure 10: The high prevalence of T-wave inversions observed in black athletes coupled with several structural modifications can result in a number of diagnostic 'grey zones'.

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Change history

  • 05 August 2014

    In the version of this article initially published online, Figure 10 incorrectly stated that the prevalence of T wave inversions in black athletes who might also exhibit coexisting right ventricular dilatation was 45%, instead of 14.3%. The error has been corrected for the HTML and PDF versions of the article.

  • 28 February 2014

    In the version of this article initially published online, the Y axis label for Figure 6, which should have read "Prevalence (%)", was missing. A typing error was also present in Figures 4, 6, and 10. The errors have been corrected for the HTML and PDF versions of the article.

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    Nabeel Sheikh & Sanjay Sharma

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Sheikh, N., Sharma, S. Impact of ethnicity on cardiac adaptation to exercise. Nat Rev Cardiol 11, 198–217 (2014). https://doi.org/10.1038/nrcardio.2014.15

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