Physiological Right Ventricular Adaptation in Elite Athletes of African and Afro-Caribbean Origin

Study Questions:

Do black athletes exhibit different characteristics of right ventricular (RV) enlargement than do white athletes?


Between 2006 and 2012, 300 consecutive black athletes (243 males) from 25 sporting disciplines were evaluated by use of electrocardiogram (ECG) and echocardiography. Results were compared with 375 white athletes and 153 sedentary control subjects (n = 69 blacks).


There were no ethnic differences between RV parameters in control subjects. Both black athletes and white athletes exhibited greater RV dimensions than control subjects. RV dimensions were marginally smaller in black athletes than in white athletes (proximal outflow tract diameter 30.9 ± 5.5 vs. 32.8 ± 5.3 mm, p < 0.001; longitudinal dimension 86.6 ± 9.5 vs. 89.8 ± 9.6 mm, p < 0.001), although only 2.3% of variation was attributable to ethnicity. RV enlargement compatible with diagnostic criteria for arrhythmogenic RV cardiomyopathy was frequently observed (proximal outflow tract ≥32 mm; 45.0% of black athletes, 58.5% of white athletes). Anterior T-wave inversion was present in 14.3% of black athletes versus 3.7% of white athletes (p < 0.001). Marked RV enlargement with concomitant anterior T-wave inversion was observed in 3.0% of black athletes versus 0.3% of white athletes (p = 0.005). Further investigation did not diagnose arrhythmogenic RV cardiomyopathy in any athlete.


Physiological RV enlargement is commonly observed in both black and white athletes. The impact of ethnicity is minimal, which obviates the need for race-specific RV reference values. However, in the context of frequent ECG repolarization anomalies in black athletes, the potential for erroneous diagnosis of arrhythmogenic RV cardiomyopathy is considerably greater in this ethnic group.


Regular, intensive exercise results in physiological biventricular cardiac adaptation. Ethnicity is an established determinant of left ventricular remodeling; across all sports, black athletes are known to exhibit more profound LV hypertrophy than white athletes. This study shows that RV enlargement is not substantially different in black athletes compared to white athletes. However, a higher prevalence of underlying ECG abnormalities (potentially suggestive of arrhythmogenic RV cardiomyopathy) among black athletes increases the potential for inappropriate disqualification of black athletes based on physiological RV enlargement.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Sports and Exercise Cardiology, Echocardiography/Ultrasound, Sports and Exercise and Imaging

Keywords: Athletes, Ethnic Groups, Cardiomyopathies, European Continental Ancestry Group, Ventricular Remodeling, Sports, Hypertrophy, Right Ventricular, Electrocardiography, African Continental Ancestry Group, Echocardiography

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