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

Abstract

Background-Regular, intensive exercise results in physiological biventricular cardiac adaptation. Ethnicity is an established determinant of left ventricular remodeling; black athletes (BAs) exhibit more profound LV hypertrophy than white athletes (WAs). Right ventricular (RV) remodeling has not been characterized in BAs, although the issue is pertinent because BAs commonly exhibit ECG anomalies that resemble arrhythmogenic RV cardiomyopathy. Methods and Results-Between 2006 and 2012, 300 consecutive BAs (n=243 males) from 25 sporting disciplines were evaluated by use of ECG and echocardiography. Results were compared with 375 WAs and 153 sedentary control subjects (n=69 blacks). There were no ethnic differences between RV parameters in control subjects. Both BAs and WAs exhibited greater RV dimensions than control subjects. RV dimensions were marginally smaller in BAs than in WAs (proximal outflow tract, 30.9±5.5 versus 32.8±5.3 mm, P<0.001; longitudinal dimension, 86.6±9.5 versus 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 BAs, 58.5% of WAs). Anterior T-wave inversion was present in 14.3% of BAs versus 3.7% of WAs (P<0.001). Marked RV enlargement with concomitant anterior T-wave inversion was observed in 3.0% of BAs versus 0.3% of WAs (P=0.005). Further investigation did not diagnose arrhythmogenic RV cardiomyopathy in any athlete. Conclusions-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 BAs, the potential for erroneous diagnosis of arrhythmogenic RV cardiomyopathy is considerably greater in this ethnic group. (Circulation. 2013;127:1783-1792.)Key Words: cardiomyopathy ◼ echocardiography ◼ electrocardiographic screening ◼ ethnicity ◼ exercise © 2013 American Heart Association, Inc.Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.112.000270Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz. Received December 6, 2012; accepted March 4, 2013. From St. George's University of London, London, United Kingdom (A.Z., S. Ghani, R.S., N.S., S. Gati, M.P., S.S.); University Hospital Lewisham, London, United Kingdom (A.Z., S. Ghani, N.S., S. Gati, S.S.); Liverpool John Moores University, Liverpool, United Kingdom (D.O.); and Imperial College Healthcare NHS Trust, London, United Kingdom (V.F.P. [WAs]). 10,11 The influence of ethnicity on athletic RV remodeling has never been characterized, even though healthy BAs frequently reveal ECG repolarization anomalies that resemble those observed in ARVC.12 Furthermore, BAs comprise a growing number of elite sports participants worldwide, and for reasons that remain incompletely under...

Comparison of Electrocardiographic Criteria for the Detection of Cardiac Abnormalities in Elite Black and White Athletes

“…frequently exhibit profound ECG alterations 7,[17][18][19][20][21] that overlap with primary cardiomyopathies, which magnifies their risk of an erroneous diagnosis.…”

“…7,14,15,17,19,20 To determine their sensitivity for the detection of hypertrophic cardiomyopathy (HCM), all 3 criteria were applied to a well-characterized cohort of young, asymptomatic athletes with HCM.…”

Cold acclimation alters the connective tissue content of the zebrafish (Danio rerio) heart

“…Pathological remodelling such as left ventricular hypertrophy and cardiac fibrosis occurs in the human heart following myocardial infarction, which leads to diastolic dysfunction and eventual failure (Jalil et al, 1988;Jalil et al, 1989;Nelson et al, 2008;Pauschinger et al, 1999). Physiological remodelling of the heart, including cardiac hypertrophy and increased contractile function, occurs in most vertebrates with exercise (Diffee et al, 2003;Natali et al, 2002;Zaidi et al, 2013) and in some species of fish with cold acclimation (Farrell et al, 1988a;Klaiman et al, 2011;Tsukuda and Kihara, 1989). In coldacclimated fish hearts, the increase in the amount of contractile machinery is thought to alleviate the loss of contractile strength caused by low temperature as well as to offset the increased load on the heart caused by an increase in blood viscosity (Graham and Farrell, 1989;Klaiman et al, 2011).…”

Signs of RV overload on the athlete’s ECG

“…Furthermore, it is also important to consider ethnicity when interpreting TWI in the right precordial leads. Convex ST-segment elevation with biphasic TWI in leads V1-V4 is present in 1 in 7 black athletes and appears to be a benign finding in the absence of other relevant clinical indicators [18]. Conversely, both in black athletes and Caucasian athletes, the presence of deep, symmetrical TWI in all 3 leads from V1 to V3, preceded by isoelectric or downsloping ST segments, is rare and should prompt further investigation to exclude ARVC [2,18].…”