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Relation of Race to Electrocardiographic Patterns in Elite American Football Players
Open accessAbstract
Objectives The purpose of this study was to establish an electrocardiographic (ECG) profile in a biracial population of highly-trained American football players.Background Intense physical training can induce cardiac structural and functional changes ("athlete's heart"), including 12-lead ECG alterations. That race might play a role in determining ECG patterns has been suggested, although not studied in a large athletic population comparing black and white athletes.Methods Electrocardiographic analysis of 1,959 elite male athletes attending the National Football League Invitational Camp from 2000 to 2005 was performed. Subjects were classified by race and player position and judged free of structural heart disease.Results Abnormal ECG patterns were present in 480 (25%) athletes and were significantly more common among black players (n = 396; 30%) compared with white players (n = 78; 13%) or other races (n = 6; 15%) (p < 0.0001). Distinctly abnormal ECG patterns, suggestive of cardiac disease, were also more common in blacks (n = 76; 6%) than whites (n = 11; 2%) (p = 0.0005). In multivariable analysis, black race was an independent predictor of abnormal ECGs (risk ratio [RR] 2.03, 95% confidence interval [CI] 1.56 to 2.64, p < 0.0001), including patterns judged distinctly abnormal (RR 2.59, 95% CI 1.18 to 5.67, p = 0.02). Abnormal ECGs were also related to player position: most frequent in wide receivers (n = 91; 35%) and least common in quarterbacks (n = 16; 14%) and place kickers (n = 8; 11%). Echocardiograms, obtained in 203 athletes (10%), did not show structural cardiac abnormalities.Conclusions Electrocardiographic abnormalities were 2-fold more common in black than in white highly-trained male American football players, with race an independent determinant of ECG pattern. These findings have important implications for pre-participation cardiovascular screening of athletes with ECGs.
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“Among highly trained American football players, the black athletes had significantly more abnormal ECG patterns, compared with their white counterparts, the most common being increased precordial voltages and diffuse T-wave inversions.”
From The Year of 2008 in Electrocardiology (2010) · cites this paper as [10]
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Recommendations for interpretation of 12-lead electrocardiogram in the athlete
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BackgroundThe Athlete's Heart in Adolescent Africans
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Addition of the Electrocardiogram to the Preparticipation Examination of College Athletes
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“Using the ECG classification described by Pelliccia et al,4 15% presented a distinctly abnormal ECG.”
BackgroundInfluentialAthletic Cardiac Remodeling in US Professional Basketball Players
Engel, D. J., Schwartz, A. J., & Homma, S. (2016) · JAMA Cardiology · doi:10.1001/jamacardio.2015.0252 · Cited by 94
“3) mL, which was increased in the NBA cohort compared with the mean in normal male individuals (73 [17] mL).”
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Cardiovascular damage resulting from chronic excessive endurance exercise.
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Self-citationThe Journal of Tehran University Heart Center
Darmānī, D.-I. ʿ.-I. P. W.-Ḫ.-I. B. (2018) · European Heart Journal · doi:10.1093/eurheartj/ehy370 · Cited by 76
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“T wave inversion in the right precordial leads can also be seen in many other conditions such as acute PE, athlete heart [107-109], Brugada syndrome, long QT syndrome caused by Fig.”
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“There is emerging evidence that racial factors have a significant impact on the physiological adaptation to exercise in athletes of African/Afro-Caribbean origin.”
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“(B) Histogram demonstrating the distribution of T-wave inversions as percentage (%) of the total cohort in the three groups.(27) †p<0.”
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BackgroundSports and Exercise Cardiology in the United States
Lawless, C. E., Olshansky, B., Washington, R., Baggish, A. L., Daniels, C. J., Lawrence, S. M., Sullivan, R. M., Kovacs, R. J., & Bové, A. A. (2014) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2013.12.033 · Cited by 45
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BackgroundImpact of ethnicity on cardiac adaptation to exercise
Sheikh, N., & Sharma, S. (2014) · Nature Reviews Cardiology · doi:10.1038/nrcardio.2014.15 · Cited by 44
Sudden cardiac death in athletes
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Ethnic differences in ventricular hypertrabeculation on cardiac MRI in elite football players
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“More abnormal ECG patterns are observed than in European athletes, most frequently left ventricular (LV) hypertrophy, early repolarisation, ST-segment elevation and T-wave inversions [1–4].”
BackgroundResultCardiac adaptation in athletes of black ethnicity: differentiating pathology from physiology
Chandra, N., Papadakis, M., & Sharma, S. (2012) · Heart · doi:10.1136/heartjnl-2012-301798 · Cited by 36
“0001).(6) These findings were reproduced by a UK study that compared ECG and echocardiographic data in 300 male black and white athletes matched for age, body surface area and participating in similar sporting disciplines.”
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“Table 6 illustrates ECG abnormalities, especially T-wave inversion and increased R/S-wave voltage, are often more common in Black than in White athletes.(14,15,17,18) While the exact mechanism for the ethnic difference remains yet to be elucidated, variations in response to blood pressure modulation during systemic tr…”
BackgroundCounterpoint/Mandatory ECG screening of young competitive athletes
Maron, B. J. (2012) · Heart Rhythm · doi:10.1016/j.hrthm.2012.04.004 · Cited by 33
Self-citationIs There Evidence for Mandating Electrocardiogram as Part of the Pre-Participation Examination?
Börjesson, M., & Dellborg, M. (2010) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0b013e318204a7b4 · Cited by 32
“Electrocardiographic changes are dependent also on ethnicity.(28,29) For example, echocardiographic studies showed that 20% of black athletes compared with 4% of white athletes will have an increased left ventricular wall thickness .”
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“These findings can be even more prevalent among black athletes.(23) This variability underscores the importance of additional testing in many athletes with ERS.”
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“Magalski et al. (2008) studied 1959 elite American football players.”
The Impact of Ethnicity on Cardiac Adaptation
Ozo, U., & Sharma, S. (2020) · European Cardiology Review · doi:10.15420/ecr.2020.01 · Cited by 28
Effect of Gender on Computerized Electrocardiogram Measurements in College Athletes
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“This finding is similar to that of previous studies.(19,21) Consistent with previous studies, the most common ECG finding in the current study was sinus bradycardia.”
Riding, N. R., Salah, O., Sharma, S., Carré, F., O’Hanlon, R., George, K., Hamilton, B. H., Chalabi, H., Whyte, G. P., & Wilson, M. G. (2012) · British Journal of Sports Medicine · doi:10.1136/bjsports-2012-091258 · Cited by 25
“Recent data suggest that an athlete’s ethnic origin may have a significant impact on their cardiovascular response to exercise.(13) 35 37 Despite no significant difference in BSA between ethnicities in the >2.”
BackgroundCounterpoint: Mandatory ECG screening of young competitive athletes
Maron, B. J. (2012) · Heart Rhythm · doi:10.1016/j.hrthm.2012.03.019 · Cited by 24
Self-citationElectrocardiographic Screening of All Infants, Children, and Teenagers Should Be Performed
Vetter, V. L. (2014) · Circulation · doi:10.1161/circulationaha.114.009737 · Cited by 24
Grey zones in cardiomyopathies: defining boundaries between genetic and iatrogenic disease
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Abnormal ECG Findings in Athletes: Clinical Evaluation and Considerations
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Electrocardiographic and Echocardiographic Findings in Elite Ghanaian Male Soccer Players
Pambo, P., Adadey, M., Agbodzakey, H., & Scharhag, J. (2019) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0000000000000801 · Cited by 23
Exercise, the Athlete's Heart, and Sudden Cardiac Death
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Hypertrophic cardiomyopathy and ultra-endurance running - two incompatible entities?
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“The ECG presented here has numerous features compatible with cardiac adaptation to exercise, including voltage criteria for LVH, ST-segment depression, a prolonged PR interval and inverted T-waves [6,12-17].”
BackgroundCardiac Screening of Young Athletes: a Practical Approach to Sudden Cardiac Death Prevention
Dhutia, H., & MacLachlan, H. (2018) · Current Treatment Options in Cardiovascular Medicine · doi:10.1007/s11936-018-0681-4 · Cited by 23
The effect of sport on computerized electrocardiogram measurements in college athletes
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“Right axis deviation 6 (13) 5 (17) 14 (21) 9 (10) 5 (23) 6 (13) 3 (18) 3 (10) 19 (18) Abnormal Q wave (V5 or aVF 0.”
Berge, H. M., Gjesdal, K., Andersen, T. E., Solberg, E. E., & Steine, K. (2014) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/sms.12274 · Cited by 21
“Anyway, the results are difficult to compare with other investigations, because some studies lack definition of ethnicity (Magalski et al., 2008; Le et al., 2010), while other studies use self-definition through questionnaires (Basavarajaiah et al., 2008a; Papadakis et al., 2011; Gati et al., 2013).”
BackgroundResultScreening athletes for cardiovascular disease in Africa: a challenging experience
Schmied, C. M., Paolo, F. M. D., Zerguini, A. Y., Dvořák, J., & Pelliccia, A. (2013) · British Journal of Sports Medicine · doi:10.1136/bjsports-2012-091803 · Cited by 21
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Pre-participation cardiovascular evaluation in Pacific Island athletes
Chatard, J., Espinosa, F., Donnadieu, R., Grangeon, J.-P., Sabot, J.-M., Guivarch, C., Dacquin, R., Raby, F.-X., Papouin, G., Viali, S., et al. (2018) · International Journal of Cardiology · doi:10.1016/j.ijcard.2018.11.012 · Cited by 20
“Clearly, PPE could not detect nor prevent 2 SCDs in the New Caledonian population confirming previous observation in athletes [17, 29, 30].”
ResultHypertrophic cardiomyopathy vs athlete's heart
Cheng, T. O. (2008) · International Journal of Cardiology · doi:10.1016/j.ijcard.2008.10.015 · Cited by 19
“Black athletes tend to show higher incidence of ECG abnormalities [49] and greater magnitude of left ventricular hypertrophy [50] than white athletes.”
BackgroundPreparticipation Screening of Young Competitive Athletes for Cardiovascular Disorders
Chandra, N., Papadakis, M., & Sharma, S. (2010) · The Physician and Sportsmedicine · doi:10.3810/psm.2010.04.1762 · Cited by 18
Zaidi, A., & Sharma, S. (2012) · Future Cardiology · doi:10.2217/fca.12.81 · Cited by 18
“reported that ECG abnormalities were twice as common in black compared with white athletes [30].”
BackgroundSudden Unexpected Death in Young Athletes: Reconsidering “Hypertrophic Cardiomyopathy”
Rowland, T. (2009) · PEDIATRICS · doi:10.1542/peds.2008-0708 · Cited by 17
Debate: challenges in sports cardiology; US versus European approaches
Hamilton, B. H., Levine, B. D., Thompson, P. D., Whyte, G. P., & Wilson, M. G. (2012) · British Journal of Sports Medicine · doi:10.1136/bjsports-2012-091311 · Cited by 16
Huttin, O., Selton‐Suty, C., Venner, C., Vilain, J.-B., Rochecongar, P., & Aliot, E. (2017) · Archives of cardiovascular diseases · doi:10.1016/j.acvd.2017.10.005 · Cited by 16
The Impact of Ethnicity on Athlete ECG Interpretation: A Systematic Review
Davis, A. J., Semsarian, C., Orchard, J. W., Gerche, A. L., & Orchard, J. J. (2022) · Journal of Cardiovascular Development and Disease · doi:10.3390/jcdd9060183 · Cited by 15
“2–40%) [17,22,24,25], but not significant in two papers [19,39] and more likely in Caucasian athletes in one paper (17.”
BackgroundAthlete's heart patterns in elite rugby players: Effects of training specificities
Chevalier, L., Kervio, G., Corneloup, L., Vincent, M.-P., Baudot, C., Rebeyrol, J.-L., Merle, F., Gencel, L., & Carré, F. (2013) · Archives of cardiovascular diseases · doi:10.1016/j.acvd.2012.10.002 · Cited by 15
Cardiac Evaluation of Collegiate Student Athletes: A Medical and Legal Perspective
Paterick, T. E., Jan, M. F., Paterick, Z. R., Umland, M. M., Kramer, C. M., Lake, P., Seward, J. B., Tajik, A. J., & Maron, B. J. (2012) · The American Journal of Medicine · doi:10.1016/j.amjmed.2012.02.017 · Cited by 15
Self-citationResting ECG findings in elite football players
Bohm, P., Ditzel, R. A., Ditzel, H., Urhausen, A. J. P., & Meyer, T. (2013) · Journal of Sports Sciences · doi:10.1080/02640414.2013.796067 · Cited by 14
“Athletes of African/Caribbean origin exhibit significantly more ECG alterations than Caucasian athletes, which is partly due to greater LV wall thickness and cavity size (Basavarajaiah et al., 2008; Magalski et al., 2008; Papadakis et al., 2009; Papadakis et al., 2011; Schmied et al., 2009).”
BackgroundEthnicity‐related variations of left ventricular remodeling in adolescent amateur football players
Pelà, G. M., Calzi, M. L., Crocamo, A., Pattoneri, P., Goldoni, M., Anedda, A., Musiari, L., Biggi, A., Bonetti, A., & Montanari, A. (2014) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/sms.12238 · Cited by 14
Corrado, D., Basso, C., Pelliccia, A., & Thiene, G. (2009) · doi:10.1093/med/9780199566990.003.032 · Cited by 13
Electrocardiogram interpretation in the athlete
Williams, E. S., Owens, D. S., Drezner, J. A., & Prutkin, J. M. (2012) · Herzschrittmachertherapie + Elektrophysiologie · doi:10.1007/s00399-012-0179-9 · Cited by 14
Electrocardiographic pattern of apparently healthy African adolescent athletes in Nigeria
Sokunbi, O. J., Okoromah, C. A. N., Ekure, E. N., Olawale, O. A., & Eke, W. S. (2021) · BMC Pediatrics · doi:10.1186/s12887-021-02557-8 · Cited by 13
“These alterations have been attributed to the physiological cardiac adaptations that occur as a consequence of systematic physical training [8] and the extent of these changes vary with the athlete’s gender, race, level-of-fitness, and type of sport [2, 9].”
BackgroundZaidi, A., & Sharma, S. (2011) · British Journal of Hospital Medicine · doi:10.12968/hmed.2011.72.5.275 · Cited by 13
Whyte, G. P., Somauroo, J. D., Wilson, M. G., & Sharma, S. (2012) · BMJ Case Reports · doi:10.1136/bcr.06.2011.4403 · Cited by 13
How Important Is the Electrocardiogram in Protecting and Guiding the Athlete?
Wellens, H. J. J., & Gorgels, A. P. M. (2011) · Circulation · doi:10.1161/circulationaha.111.040923 · Cited by 13
A discussion of electrocardiographic screening and sudden cardiac death prevention
Vetter, V. L., & Dugan, N. P. (2013) · Current Opinion in Cardiology · doi:10.1097/hco.0b013e32835dd0fe · Cited by 12
“[56] 964 university athletes; 18–21 years 44.”
BackgroundJacob, D., Main, M. L., Gupta, S. K., GOSCH, K. L., McCoy, M. B., & Magalski, A. (2015) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2015.03.005 · Cited by 12
“However, a previous study [17] evaluating a more elite population of prospective professional football also observed a lower prevalence in black American athletes than reported in elite African/Afro-Caribbean European athletes by Sheikh et al.”
BackgroundResultInfluentialSelf-citationVisual or computer-based measurements: important for interpretation of athletes’ ECG
Berge, H. M., Steine, K., Andersen, T. E., Solberg, E. E., & Gjesdal, K. (2014) · British Journal of Sports Medicine · doi:10.1136/bjsports-2014-093412 · Cited by 12
Differences in Cardiac Remodeling Associated With Race
Pelliccia, A. (2008) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2008.02.063 · Cited by 12
Overview of Sudden Cardiac Death in Young Athletes
Sheikh, N., & Sharma, S. (2011) · The Physician and Sportsmedicine · doi:10.3810/psm.2011.11.1936 · Cited by 11
Echocardiographic assessment of left ventricular hypertrophy in elite athletes
Khamis, R., & Mayet, J. (2008) · Heart · doi:10.1136/hrt.2008.153783 · Cited by 11
“There are some ECG changes that are considered ‘‘normal’’ for highly trained athletes.(8) Examples of these include a mildly raised PR interval, mildly increased R or S wave voltage (up to 29 mm) and early repolarisation (STsegment elevation .”
BackgroundDefining the Limits of Athlete’s Heart
Sedehi, D., & Ashley, E. A. (2010) · Circulation · doi:10.1161/cir.0b013e3181d7308a · Cited by 11
Uberoi, A., Sadik, J., Lipinski, M. J., Van, V., & Froelicher, V. F. (2013) · The Physician and Sportsmedicine · doi:10.3810/psm.2013.09.2025 · Cited by 10
Electrocardiographic and Echocardiographic Findings in Black Athletes: A General Review
Pambo, P., & Scharhag, J. (2019) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0000000000000754 · Cited by 9
“8 (14-35) United Kingdom 6 disciplines, endurance, and”
BackgroundInfluentialThe Role of Screening Electrocardiograms in the Evaluation of ROTC Cadets Applying for Flight Status
Liesemer, K. N., Flanagan, R., Johnson, E., Devenport, M., Cartwright, V. W., & Puntel, R. (2010) · Military Medicine · doi:10.7205/milmed-d-09-00090 · Cited by 9
Battle, R. W., Mistry, D. J., Malhotra, R., MacKnight, J. M., Saliba, E. N., & Mahapatra, S. (2011) · Clinics in Sports Medicine · doi:10.1016/j.csm.2011.03.001 · Cited by 8
“Race can accentuate this as well, with male black football players twice as likely to have ECG abnormalities as their white counterparts.(30) Angiotensin gene polymorphisms may also predispose athletes to abnormal remodeling and thus more extensive increases in LV mass and wall thickness.”
BackgroundT wave inversions in athletes: A variety of scenarios
Stein, R., & Malhotra, A. (2015) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2015.01.011 · Cited by 8
“Limited studies in American football players reveal that black athletes exhibit a greater prevalence of T-wave inversions and ST-segment elevation than white athletes [13,14].”
BackgroundMovahed, M. R., Sattur, S., & Bates, S. (2019) · Critical Pathways in Cardiology A Journal of Evidence-Based Medicine · doi:10.1097/hpc.0000000000000168 · Cited by 7
EKG-Diagnostik bei Leistungssportlern
Preßler, A., & Halle, M. (2012) · Herz · doi:10.1007/s00059-012-3636-7 · Cited by 7
Electrocardiographic Abnormalities in Medically Screened Military Aircrew
Boos, C. J., Jamil, Y., Park, M., Moy, W., Khanna, V., Timperley, A. C., & Sharma, S. (2012) · Aviation Space and Environmental Medicine · doi:10.3357/asem.3276.2012 · Cited by 7
Filling the gap of understanding the athlete’s ECG
Pelliccia, A. (2012) · European Journal of Preventive Cardiology · doi:10.1177/2047487312467872 · Cited by 7
Bonny, A., Lele, E. C. B., Mandenguè, S. H., Larrazet, F. S., & Amara, W. (2013) · La Presse Médicale · doi:10.1016/j.lpm.2012.11.002 · Cited by 6
Assanelli, D., Ermolao, A., Carré, F., Deligiannis, A. P., Klaus, M., Mohamed, T., Cesana, B. M., Levaggi, R., Paola, A., & Sanjay, S. (2013) · Internal and Emergency Medicine · doi:10.1007/s11739-013-0955-5 · Cited by 6
Maron, B. J. (2012) · Elsevier eBooks · doi:10.1016/b978-1-4377-0398-6.00069-x · Cited by 6
Self-citation
Metadata
- Authors
- Magalski, A., Maron, B. J., Main, M. L., McCoy, M., Florez, A., Reid, K. J., Epps, H. W., Bates, J., & Browne, J. E.
- Affiliations
- Minneapolis Heart Institute Foundation (US)
- Saint Louis University (US)
- University of Missouri–Kansas City (US)
- Corresponding author
- Magalski, Anthony
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2008-06
- Volume
- 51
- Issue
- 23
- Pages
- 2250-2255
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2018184929
- Cited by
- 161
- References
- 20
- Citations by year
- 2026: 2 · 2025: 5 · 2024: 2 · 2023: 1 · 2022: 2 · 2021: 8 · 2020: 6 · 2019: 5 · 2018: 7 · 2017: 7 · 2016: 7 · 2015: 5 · 2014: 15 · 2013: 14 · 2012: 28
- FWCI
- 11.39
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Effects of Exercise
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Genetics and Physical Performance
- Keywords
- electrocardiographic abnormalities, race, athlete's heart, American football players, Black athletes, pre-participation cardiovascular screening, playing position, echocardiography
- MeSH terms
- Adult, Black or African American, Cardiovascular Physiological Phenomena, Electrocardiography, Football, Heart Rate, Humans, Male, United States, Odds Ratio, White People
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