The impact of ethnicity on abnormal electrocardiographic findings in elite Brazilian football players: B-pro foot ECG pilot study
Authors: Ferrari F , Donelli Da Silveira A , Dalcin Dilda G , Faria Isfer De Lima G , Machado Arantes M , Bianchini Cardoso F , Christo Aleixo H , Gustavo Marin Emed L , Guimaraes F , Porto Luciano Coimbra F , Custodio Da Silva H , Zini C , Bruno Costa Murara P , Nairo Da Cunha Ribeiro Junior J , Stein R 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Introduction
Black athletes may be more likely to have uncommon electrocardiogram findings than white athletes. The prevalence of abnormal electrocardiographic findings in elite Brazilian football players (EBFP) of different ethnicities is unknown.

Purpose
To compare the prevalence of these changes and their correlation with the echocardiogram and cardiac magnetic resonance (CMR) in Caucasian, Mixed-race (MR), and Afro-Brazilian (AB) EBFP.

Methods
A multicenter cross-sectional descriptive study was conducted with exams performed on EBFP as a pre-participation assessment from February 18, 2002, through October 20, 2022.

Results
4,363 EBFP from 51 professional clubs (from all five regions of Brazil; 15 states, and 21 cities), aged 15-35 years (median: 19 years; IQR: 16-23) were evaluated. 2,027 were Caucasians, 1,324 were MRs, and 1,012 were ABs. T-wave inversion (TWI) in leads II and aVF (4.2% vs. 2.3%), V5 (4.0% vs. 1.7%), and in V5-V6 (3.0% vs. 1.4%) was more common in AB than in Caucasian players, respectively (P = 0.002 for all comparisons). In addition, AB demonstrated a significantly greater prevalence of inferolateral TWI (2.3%) than Caucasian (1.1%), and MR (1.3%) EBFP, respectively. TWI in leads V1-V3 in Caucasians or MRs &gt;16 years was present in 0.9% (30/3,351). PR interval ≥400 ms was observed in one Caucasian and in one AB athlete. The Wolff-Parkinson-White pattern was identified in two Caucasians, and a suggestive case of a type 2 Brugada Pattern in one Caucasian. Overall, 208 (4.8%) EBFP had electrocardiographic changes considered to be abnormal (4.5% in Caucasians, 4.8% in MRs, and 5.2% in ABs). Of these, 150/208 (72.1%) underwent an echocardiogram. Isolated inferior TWI was not associated with echocardiographic abnormalities (n = 25), similar to persistent juvenile TWI patterns (in Caucasians or MRs). However, TWI in inferolateral leads was associated with 10.5% echocardiographic abnormalities (4/38). Of these, 75% (3/4) had abnormal CMR findings: one AB with hypertrophic cardiomyopathy (CMP), and two Caucasians with non-compaction CMP; one Caucasian with an abnormal echocardiogram demonstrated normal CMR, suggesting "athlete's heart". Finally, one AB had normal echocardiogram results, but the CRM showed a finding compatible with apical hypertrophic CMP.

Conclusion
In this large cohort of EBFP, approximately 5% of the electrocardiographic findings were considered abnormal. In those with inferolateral TWI, the use of CMR may indicate the presence of potentially malignant cardiac disease, even with normal echocardiographic findings. AB ethnicity was associated with a higher prevalence of TWI in the inferior and/or lateral leads in comparison to Caucasian or MR ethnicities.