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racial differences in EKG, LVH in young athletes

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  • racial differences in EKG, LVH in young athletes

    Racial differences in ECGs, LVH in young athletes
    JUNE 2, 2008 |
    London, UK and Kansas City, MO - Two new studies are among the first to show that there are significant racial differences between young athletes in terms of ECG patterns and left ventricular hypertrophy [1,2]. The findings have important implications when it comes to cardiovascular screening of young people engaging in sports, say the researchers and an accompanying editorialist [3] in the June 10, 2008 issue of the Journal of the American College Cardiology.

    Dr Anthony Magalski (Mid-America Heart Institute, Kansas City, MO) and colleagues found that ECG abnormalities were twice as common in black than in white highly trained male American football players. Meanwhile, Dr Sandeep Basavarajaiah (Kings College Hospital, London, UK) et al found that black male athletes appear to develop a greater magnitude of left ventricular hypertrophy (LVH) than white athletes. Their results suggest, however, that this is mainly due to physiologic LVH rather than hypertrophic cardiomyopathy (HCM).

    Both of these findings illustrate the importance of taking ethnicity into account when performing screening, say the researchers, because there are racial differences that probably don't represent any increased incidence of problems with the heart structurally. If these differences are not considered, it is likely that black athletes will generate more "false-positive" results and may be unfairly penalized, they note.

    In his accompanying editorial, Dr Antonio Pelliccia (Institute of Sports Medicine and Science, Rome, Italy), agrees: "It appears that young black individuals are in a particularly unfavorable position when exposed to preparticipation screening programs." The two new studies "are of particular clinical value in adjusting our biased knowledge of normality—derived from previous investigations made in white subjects—by introducing the novelty of race-related appropriate standards for interpretation of ECG pattern and physiologic cardiac remodeling in athletes," he asserts.


    Player position, exact ethnicity, affected findings

    The UK researchers and Pelliccia note as background that sudden cardiac deaths disproportionately affect young black athletes, but the studies that have been done to establish the upper limits of LV wall thickness in athletes, thereby differentiating physiologic LVH—or "athlete's heart"—from HCM, have mostly been done in whites.

    In their study, Magalski et al retrospectively examined a large cohort of 1959 collegiate football players—of whom 67% were black—and found a substantially larger proportion of abnormal ECGs in black compared with white athletes (30% vs 13%, p<0.001). Distinctly abnormal ECGs, suggesting the presence of cardiac disease, were found in 5.8% of blacks vs only 1.8% of whites (p<0.005). Overall, black race was the only independent predictor for all of the abnormal ECGs (relative risk 2.03) and specifically, for the distinctly abnormal ECGs (RR 2.59).

    In addition, the presence of abnormal ECGs was somehow related to football player position, with wide receivers, defensive backs, and running backs showing more than twice the abnormalities than the other players.

    Meanwhile, Basavarajaiah and colleagues conducted a comparative ECG study of cardiac dimensions in 300 black vs 300 white highly trained young athletes in the UK, all of whom also underwent echo. They also included for comparison 150 black and white sedentary individuals.

    Black athletes showed greater LV wall thickness and mass but similar cavity size compared with white athletes matched for age, body size, and level of blood pressure. In addition, a larger proportion of black athletes (18% vs 4%) showed LV wall thickness above normal values (>12 mm), including an important subset of 3% showing wall thickening of 15 mm or greater, suggesting the presence of HCM.

    They also found that ECG changes suggestive of LV hypertrophy were much more common in black athletes with evidence of LV hypertrophy (68% vs 40% of white athletes, p<0.001). Moreover, certain ECG abnormalities that are consistently found in HCM, such as deep T-wave inversion in precordial leads, occurred in a substantial minority of black (12%) but in not white athletes.

    Another valuable insight from the British study is that ancestral origin of the black athletes was important—the LV hypertrophy was predominantly seen in black individuals originating from the Caribbean or West Africa and was unusual in blacks from East Africa.


    Will findings mean more blacks disqualified from sports?

    Currently, mass preparticipation screening of young athletes, routinely including 12-lead ECG, has been in practice in Italy for 25 years and has been supported by the European Society of Cardiology and the International Olympic Committee, Pelliccia says in his editorial. In the US, the inclusion of 12-lead ECG in preparticipation screening is still much debated, however, with recent discussion focusing on collegiate and high school athletes in particular.

    Pelliccia says: "Black athletes have a disproportionately higher probability of showing abnormal ECG patterns compared with their white teammates and, specifically, of presenting those alterations that unavoidably raise questions of underlying HCM. Consequently echocardiography or other imaging testing (ie, cardiac MRI) will be needed to solve the ambiguity of abnormal ECG patterns in a larger proportion of black compared with white individuals, multiplying the occurrence of false-positive results and thus the probability for black athletes to be disqualified from competitive sports."

    He continues, "The data suggest the impracticality of cardiovascular screening programs in large populations of black athletes, not only for the expected large proportion of ECG abnormalities and the disproportionate request for imaging and other testing in selected cases, but also for the limited access to medical services of a sizable proportion of the black population, which includes several millions of uninsured young individuals."

    But Magalski told heartwire that while he understands Pelliccia's concerns that more black athletes than white may be unnecessarily disqualified from competitive sports if routine ECG screening takes place, he does not believe this will happen if people take into consideration these newly identified racial differences.

    The most important take-home message . . . is that we just need to bear these racial differences in mind if or when we decide to do an ECG in a young athlete.
    "The most important take-home message from these studies is that we just need to bear these racial differences in mind if or when we decide to do an ECG in a young athlete. There are racial differences that probably don't represent any increased incidence of problems with the heart structurally. In our paper, the percentage of distinctly abnormal ECGs is still pretty small—somewhere between 2% and 5%. This is information that people need to be aware of, and maybe we need to change our criteria a bit about how we read ECGs in young athletes, compared with a 60-year old granddad with coronary artery disease. This is a different population.

    "Ours is the first study that has really concentrated on looking at the ECGs of black athletes," he continues. "Clearly, a limitation of our study is that we got echoes on only 10% of the almost 2000 participants, for various reasons. However, 40% of those with abnormal ECGs got an echo, and there were just a couple who had borderline wall-thickness abnormalities. In our situation, further testing did not end up disqualifying any more black than white athletes."

    He does agree, however, that it's clear that "if you did mass ECG screening, we'd have to do further testing—such as echo or MRI—in more blacks than in whites, and the costs could be quite high." Insurance coverage in the US could be a problem here, he conceded, with varying arrangements for high school athletes and college athletes.


    University of Kansas registry may reveal more

    "Clearly, we need more information," Magalski adds. He applauds the UK study by Basavarajaiah et al, which "is prospective in nature, with good echo and ECG data," and notes that a prospective registry is ongoing at the University of Kansas, in around 650 black and white student athletes, in whom ECGs and echoes are being performed to better document any racial differences, structurally or with regard to the ECGs.

    This registry is also novel in that data are being collected on women athletes, to look at any potential gender differences, Magalski said. "Women are the other population that is underrepresented in this conversation, and 50% of our participants are female."

    Sources
    Magalski A, Maron BJ, Main ML et al. Relation of race to electrocardiographic patterns in elite American football players. J Am Coll Cardiol 2008; 51:2250-2255.
    Basavarajaiah S, Boraita A, Whyte G, et al. Ethnic differences in left ventricular remodeling in highly trained athletes. Relevance to differentiating physiologic left ventricular hypertrophy from hypertrophic cardiomyopathy. J Am Coll Cardiol 2008; 51:12256-2262.
    Pellicia A. Differences in cardiac remodeling associated with race. Implications for preparticipation screening and the unfavorable situation of black athletes. J Am Coll Cardiol 2008; 51:2263-2265.

    Related links
    Abnormal ECG patterns in athletes: An initial expression of underlying cardiomyopathy?
    [HeartWire > Electrophysiology; Jan 09, 2008]
    Sudden cardiac death more common than thought among the young
    [HeartWire > News; Sep 10, 2007]
    Preparticipation electrocardiographic screening not required for competitive athletes
    [HeartWire > News; Mar 16, 2007]
    Grounding athletes with heart disease: Knowing when to say no to competitive sports
    [HeartWire > Features; Jan 02, 2007]

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