A New Tool to Aid the Differential Diagnosis of Physiological Remodelling from Cardiac Pathology When Assessing Left Ventricle, Left Atrial and Aortic Structure and Function in Male Arab and Black Paediatric Athletes.

Aim: To determine if published Z-scores for left ventricular (LV), left atrial (LA) and aortic structure as well as indices of LV function (Doppler and TDI) in paediatric athletes and non-athletes are appropriate for application in male Arab and black paediatric athletes. If inappropriate, we aim to provide new nomograms and Z-scores for clinical application. Methods: 417 (297 Arab, 120 black) male paediatric (11-18 years) athletes, were evaluated by 2D echocardiography as per British Society of Echocardiography recommendations, and biological age (by radiological X-ray) assessment. Z-scores were tested by residual and correlation analysis together with visual inspection. New Z-scores involved allometric (a*BSA(b+c*chronological age)) and second-order polynomial (y=a*chronological age2+b*chronological age+c) equations for measures of cardiac size and indices of LV function, respectively. Results: Residual linear regression, correlation analysis and visual inspection revealed published z-scores in white peri-pubertal footballers and paediatric non-athletes to be inappropriate for application in male Arab and black paediatric athletes. Residual linear regression revealed new Z-scores for measures of LV, LA and aortic root size to be independent of BSA, ethnicity, chronological and biological age. Residual linear regression revealed new Z-scores for measures of function to be independent of chronological age. Conclusion: Our new z-scores may aid differential diagnosis of suspected pathology versus physiology remodelling, in cardiac screening of the Arab and black paediatric athlete. Nomograms are provided to assist the tracking of the paediatric athlete necessitating annual follow-up and Excel z-score calculation to facilitate use in day-to-day practice.

Protecting the stars of tomorrow: do international cardiovascular preparticipation screening policies account for the paediatric athlete? A systematic review and quality appraisal.

OBJECTIVE: (1) Identify and review current policies for the cardiovascular screening of athletes to assess their applicability to the paediatric population and (2) evaluate the quality of these policy documents using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool. DESIGN: Systematic review and quality appraisal of policy documents. DATA SOURCES: A systematic search of PubMed, MEDLINE, Scopus, Web of Science, SportDiscus and CINAHL. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: An article was included if it was a policy/position statement/guideline/consensus or recommendation paper relating to athletes and cardiovascular preparticipation screening. RESULTS AND SUMMARY: Of the 1630 articles screened, 13 met the inclusion criteria. Relevance to paediatric athletes was found to be high in 3 (23%), moderate in 6 (46%) and low in 4 (31%), and only 2 provide tailored guidance for the athlete aged 12-18 years. A median 5 related citations per policy investigated solely paediatric athletes, with study designs most commonly being retrospective (72%). AGREEII overall quality scores ranged from 25% to 92%, with a median of 75%. The lowest scoring domains were rigour of development; (median 32%) stakeholder involvement (median 47%) and Applicability (median 52%). CONCLUSION: Cardiac screening policies for athletes predominantly focus on adults, with few providing specific recommendations for paediatric athletes. The overall quality of the policies was moderate, with more recent documents scoring higher. Future research is needed in paediatric athletes to inform and develop cardiac screening guidelines, to improve the cardiac care of youth athletes.

Diagnostic accuracy and Bayesian analysis of new international ECG recommendations in paediatric athletes.

OBJECTIVE: Historically, electrocardiographic (ECG) interpretation criteria for athletes were only applicable to adults. New international recommendations now account for athletes ≤16 years, but their clinical appropriateness is unknown. We sought to establish the diagnostic accuracy of new international ECG recommendations against the Seattle criteria and 2010 European Society of Cardiology (ESC) recommendations in paediatric athletes using receiver operator curve analysis. Clinical context was calculated using Bayesian analysis. METHODS: 876 Arab and 428 black male paediatric athletes (11-18 years) were evaluated by medical questionnaire, physical examination, ECG and echocardiographic assessment. ECGs were retrospectively analysed according to the three criteria. RESULTS: Thirteen (1.0%) athletes were diagnosed with cardiac pathology that may predispose to sudden cardiac arrest/death (SCA/D) (8 (0.9%) Arab and (5 (1.2%) black)). Diagnostic accuracy was poor (0.68, 95% CI 0.54 to 0.82) for 2010 ESC recommendations, fair (0.70, 95% CI 0.54 to 0.85) for Seattle criteria and fair (0.77, 95% CI 0.61 to 0.93) for international recommendations. False-positive rates were 41.0% for 2010 ESC recommendations, 21.8% for Seattle criteria and 6.8% for international recommendations. International recommendations provided a positive (+LR) and negative (-LR) post-test likelihood ratio of 9.0 (95% CI 5.1 to 13.1) and 0.4 (95% CI 0.2 to 0.7), respectively. CONCLUSION: In Arab and black male paediatric athletes, new international recommendations outperform both the Seattle criteria and 2010 ESC recommendations, reducing false positive rates, while yielding a 'fair' diagnostic accuracy for cardiac pathology that may predispose to SCA/D. In clinical context, the 'chance' of detecting cardiac pathology within a paediatric male athlete with a positive ECG (+LR=9.0) was 8.3%, whereas a negative ECG (-LR=0.4) was 0.4%.

Impact of geographical origin upon the electrical and structural manifestations of the black athlete's heart.

Aims: Black athletes demonstrate an increased prevalence of repolarization anomalies and left ventricular hypertrophy compared to their white counterparts. Recent international recommendations for electrocardiogram (ECG) interpretation in athletes now account for some of these observations, but little attention is given to whether the heart of the black athlete is universal, or whether substantial differences exist according to geographic origin. Our aim was to examine the impact of geographical origin upon the electrical-and structural manifestations of the black athlete's heart. Methods and results: A total of 1698 male competitive athletes participating in mixed sports presented at our organization for 12 lead-ECG led pre-participation screening, with 1222 athletes undergoing systematic echocardiography. Black athletes were categorized against United Nations defined geographical regions (North, East, Middle and West Africa, African American/Caribbean, South American, and West Asia) and compared with a cohort of non-black athletes who shared a close geographical boarder with Africa (South European White and Arabic North African). The prevalence of an abnormal ECG suggestive of cardiac pathology significantly varied by geographical origin. Repolarization abnormalities were significantly more common among West (6.4%) and Middle African (8.5%) athletes than East (1.5%) and North Africans (1.2%) (P < 0.05). Left ventricular hypertrophy was significantly more common among African-American/Caribbean (9.5%) and West African (5%) athletes than West Asian (0.8%), East African (0%), and North African (0%) athletes (P < 0.05). This result remained after accounting for body size. Conclusion: The collective term 'black' should not imply that the hearts of all black athletes are universally comparable. There is considerable variability in the cardiac electrical and structural remodelling response to exercise that appears to be dependent on geographic origin.

Prevalence and significance of T-wave inversion in Arab and Black paediatric athletes: Should anterior T-wave inversion interpretation be governed by biological or chronological age?

BACKGROUND: International electrocardiographic (ECG) recommendations regard anterior T-wave inversion (ATWI) in athletes under 16 years to be normal. DESIGN: The aim of this study was to identify the prevalence, distribution and determinants of TWI by ethnicity, chronological and biological age within paediatric athletes. A second aim was to establish the diagnostic accuracy of international ECG recommendations against refinement within athletes who present with ECG variants isolated to ATWI (V1-V4) using receiver operator curve analysis. Clinical context was calculated using Bayesian analysis. METHODS: Four hundred and eighteen Arab and 314 black male athletes (11-18 years) were evaluated by ECG, echocardiogram and biological age (by radiological X-ray) assessment. RESULTS: A total of 116 (15.8%) athletes presented with ATWI (V1-V4), of which 96 (82.8%) were observed in the absence of other ECG findings considered to be abnormal as per international recommendations for ECG interpretation in athletes; 91 (12.4%) athletes presented with ATWI confined to V1-V3, with prevalence predicted by black ethnicity (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.3-3.5) and biological age under 16 years (OR 2.0, 95% CI 1.2-3.3). Of the 96 with ATWI (V1-V4) observed in the absence of other ECG findings considered to be abnormal, as per international recommendations for ECG interpretation in athletes, diagnostic accuracy was 'fail' (OR 0.47, 95% CI 0.00-1.00) for international recommendations and 'excellent' (OR 0.97, 95% CI 0.92-1.00) when governed by biological age under 16 years, providing a positive and negative likelihood ratio of 15.8 (95% CI 1.8-28.1) and 0.0 (95% CI 0.0-0.8), respectively. CONCLUSION: Interpretation of ECG variants isolated with ATWI (V1-V4) using international recommendations (chronological age <16 years) warrants caution, but governance by biological age yielded an 'excellent' diagnostic accuracy. In the clinical context, the 'chance' of detecting cardiac pathology within a paediatric male athlete presenting with ATWI in the absence of other ECG findings considered to be abnormal, as per international recommendations for ECG interpretation in athletes (positive likelihood ratio 15.8), was 14.4%, whereas a negative ECG (negative likelihood ratio 0.0) was 0%.

Performance of the BMJ learning training modules for ECG interpretation in athletes.

To assess the accuracy of interpreting the athlete's ECG both pre and post a series of online training modules among a range of healthcare professionals. 10 512 healthcare professionals from 138 different nations commenced the online course. These were primarily doctors (43%), nurses (18.4%) and other healthcare professionals (3.9%). The users came from 102 different specialities, with General Practice/Family Medicine (24.5%), Cardiology (10.6%), Emergency Medicine (8.7%) and Sports Medicine (6.6%) predominating. Among the 2023 users who completed both the pre-course and post-course test, there was an overall improvement of 15.3% (95% CI 13.9% to 16.6%; p<0.001). 930 completed all four other modules, and these users fared significantly better (18.7% increase; 95% CI 17.3 to 20.0) than those completing no additional modules (11.7% increase; 95% CI 3.3 to 17.7, p=0.036). Demographic analysis showed that while the starting pre-test scores varied significantly between profession/specialty groups (57.8%-82.6%), post-test scores were largely consistent (80.8%-84.6%). Although users showed the most improvement when interpreting primary electrical diseases (12.4% increase), it was also an area of notable weakness compared with the modules of normal training-related findings and cardiomyopathies. With the evolving criteria for ECG interpretation eliciting ever improving levels of specificity and sensitivity in the detection of conditions associated with sudden cardiac death among athletes, training is required to ensure the infrastructure and personnel is in place to uphold these standards. The BMJ Learning course presented is a valuable first step and demonstrates that such an online tool can be effective in aiding ECG interpretation among healthcare professionals globally.

International recommendations for electrocardiographic interpretation in athletes.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

Electrical and structural adaptations of the paediatric athlete's heart: a systematic review with meta-analysis.

AIM: To describe the electrocardiographic (ECG) and echocardiographic manifestations of the paediatric athlete's heart, and examine the impact of age, race and sex on cardiac remodelling responses to competitive sport. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Six electronic databases were searched to May 2016: MEDLINE, PubMed, EMBASE, Web of Science, CINAHL and SPORTDiscus. INCLUSION CRITERIA: (1) Male and/or female competitive athletes, (2) participants aged 6-18 years, (3) original research article published in English language. RESULTS: Data from 14 278 athletes and 1668 non-athletes were included for qualitative (43 articles) and quantitative synthesis (40 articles). Paediatric athletes demonstrated a greater prevalence of training-related and training-unrelated ECG changes than non-athletes. Athletes ≥14 years were 15.8 times more likely to have inferolateral T-wave inversion than athletes <14 years. Paediatric black athletes had significantly more training-related and training-unrelated ECG changes than Caucasian athletes. Age was a positive predictor of left ventricular (LV) internal diameter during diastole, interventricular septum thickness during diastole, relative wall thickness and LV mass. When age was accounted for, these parameters remained significantly larger in athletes than non-athletes. Paediatric black athletes presented larger posterior wall thickness during diastole (PWTd) than Caucasian athletes. Paediatric male athletes also presented larger PWTd than females. CONCLUSIONS: The paediatric athlete's heart undergoes significant remodelling both before and during 'maturational years'. Paediatric athletes have a greater prevalence of training related and training-unrelated ECG changes than non-athletes, with age, race and sex mediating factors on cardiac electrical and LV structural remodelling.

International criteria for electrocardiographic interpretation in athletes: Consensus statement.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

International Recommendations for Electrocardiographic Interpretation in Athletes.

Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural, or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly over the last decade; pushed by a growing body of scientific data that both tests proposed criteria sets and establishes new evidence to guide refinements. On February 26-27, 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington, to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.

Severely vitamin D-deficient athletes present smaller hearts than sufficient athletes.

BACKGROUND: Vitamin D (25(OH)D) deficiency has associations with bowl/colon cancer, arthritis, diabetes, and cardiovascular disease. Many athletes are vitamin D deficient, yet no studies have examined the association between 25(OH)D status and cardiac structure and function in healthy athletes. DESIGN: A total of 506 national-level athletes [football (50%), handball (23%), volleyball (16%), and basketball (11%)] and 244 control participants presented for precompetition medical assessment. Controls were healthy individuals registered with a sporting federation undertaking <2 h of exercise per week. METHODS: All individuals undertook a physical examination, 12-lead electrocardiogram, echocardiogram, and serum 25(OH)D evaluation. RESULTS: From 506 athletes and 244 controls, 23 and 12.3% demonstrated 25(OH)D sufficiency (>30 ng/ml), 30 and 23.4% insufficiency (20-30 ng/ml), 37.2 and 48.8% deficiency (10-20 ng/ml), and 11 and 15.6% severe deficiency (<10 ng/ml). Severely 25(OH)D-deficient athletes present significantly (p < 0.05) smaller aortic root and left atria diameters, intraventricular septum diameter (IVSd), left ventricular diameter during diastole (LVIDd), left ventricular mass (LVM), left ventricular volume during diastole (LVvolD), and right atrial (RA) area than insufficient and sufficient athletes. Furthermore, following logarithmic transformation adjusting 25(OH)D for age, body surface area, ethnicity, and athletic participation, positive associations were observed between 25(OH)D and IVSd, LVIDd, posterior wall thickness during diastole, LVM, and LVvolD in athletes but not in the control participants. CONCLUSIONS: Severely 25(OH)D-deficient athletes present significantly smaller cardiac structural parameters than insufficient and sufficient athletes. Future research should investigate the precise mechanism(s) causing cardiac hypertrophy with increases in serum 25(OH)D in healthy athletes.

Systematic echocardiography is not efficacious when screening an ethnically diverse cohort of athletes in West Asia.

BACKGROUND: The clinical and economic value of including systematic echocardiography (ECHO) alongside the 12-lead electrocardiograpm (ECG) when undertaking pre-participation screening in athletes has not been examined, yet several sporting organistations recommend its inclusion. DESIGN: To examine the efficacy of systematic ECHO alongside the ECG, to identify sudden cardiac death (SCD) disease and to provide a cost-analysis of a government-funded pre-participation screening programme. METHODS: A total 1628 athletes presented for cardiological consultation, ECG, and ECHO as standard, with further cardiac examinations performed if necessary to confirm or exclude pathology. The efficacy of systematic ECHO was compared to an ECG-led programme, with ECHO reserved as a follow-up examination. RESULTS: To screen 1628 athletes with ECG and ECHO cost US$743,996. There were 54 24-h-blood pressure/ECG Holter recordings, 62 exercise tests, 25 CMRs, two electrophysiological studies, and two genetic tests, which cost US$67,734: total US$811,730. Eight athletes (0.5%) were identified with hypertrophic cardiomyopathy (HCM) and two (0.1%) with Wolff-Parkinson-White syndrome. The cost per identifed athlete was US$81,173. All 10 athletes presented an abnormal ECG. No athlete diagnosed with HCM was identified by ECHO in isolation. When adopting a ECG-led screening protocol, 15% of athletes required ECHO as a follow-up examination, resulting in a US$380,600 cost reduction (47% saving), with the cost per diagnosis reduced to US$43,113. CONCLUSIONS: Athletes diagnosed with a disease associated with SCD were identified via an abnormal ECG and/or physical examination, personal symptoms, or family history. Screening athletes with systematic ECHO is not economically or clinically effective.

Comparison of three current sets of electrocardiographic interpretation criteria for use in screening athletes.

BACKGROUND: An increasing number of sporting bodies report unacceptably high levels of false-positive ECGs when undertaking pre-participation cardiac screening. To address this issue, modified ECG interpretation criteria have become available for use within athletes. OBJECTIVE: This study assessed the accuracy of the new 2014 'Refined Criteria' against the 2013 Seattle Criteria and the 2010 European Society of Cardiology (ESC) recommendations in a cohort of Arabic, black and Caucasian athletes. METHODS: 2491 male athletes (1367 Arabic, 748 black and 376 Caucasian) undertook pre-participation screening including a 12-lead ECG, with further investigation(s) upon indication. RESULTS: Ten athletes (0.4%) were identified with cardiac pathology; seven with hypertrophic cardiomyopathy (HCM; five black and two Arabic) and three Arabs with Wolff-Parkinson-White syndrome (WPW). All three ECG criteria were 100% sensitive identifying all cases of HCM and WPW. The 2014 Refined Criteria reduced (p<0.0001) the prevalence of an abnormal ECG to 5.3% vs 11.6% (Seattle Criteria) and 22.3% (2010 ESC recommendations). The 2014 Refined Criteria significantly (p<0.0001) improved specificity (94.0%) across all ethnicities compared with the Seattle Criteria (87.5%) and ESC recommendations (76.6%). Black athletes continue to present a higher prevalence (p<0.0001) of abnormal ECGs compared with Arabic and Caucasian athletes (10% vs 3.6% and 2.1%). CONCLUSIONS: The 2014 Refined Criteria for athlete ECG interpretation outperformed both the 2013 Seattle Criteria and the 2010 ESC recommendations by significantly reducing the number of false-positive ECGs in Arabic, black and Caucasian athletes while maintaining 100% sensitivity for serious cardiac pathologies.

ECG and morphologic adaptations in Arabic athletes: are the European Society of Cardiology's recommendations for the interpretation of the 12-lead ECG appropriate for this ethnicity?

AIMS: To examine the cardiac structure and function of Arabic athletes and to establish if the European Society of Cardiology (ESC) guidelines for the interpretation of an athlete's ECG are applicable to this ethnicity. METHODS: 600 high-level Arabic, 415 Black African, 160 Caucasian male athletes (exercising ≥6 h/week) and 201 Arabic controls presented for ECG and echocardiographic screening. RESULTS: 9 athletes (0.7%) were identified with a cardiac pathology associated with sudden cardiac death. Two Arabics (0.3%) and five Black Africans (1.2%) were diagnosed with hypertrophic cardiomyopathy; a prevalence four times greater in Black African compared to Arabic athletes. Arabic athletes had significantly greater (p<0.05) left ventricular (LV) end-diastolic diameters, maximal LV wall thicknesses and LV mass compared with controls; yet were significantly smaller than Black African and Caucasian athletes. The percentage of athletes demonstrating LV hypertrophy (≥12 mm) was comparable between Arabic, Black African and Caucasian populations (0.5%, 0.5% and 0.6%, respectively). There was no difference in the frequency of an uncommon and training-unrelated ECG between Arabic and Caucasian. However, Black Africans demonstrated a significantly greater prevalence than Arabic and Caucasian athletes (20% vs 8.4% and 6.9%, p<0.001); specifically more right/left atrial enlargement and T wave inversion. CONCLUSIONS: Arabic athletes present significantly smaller cardiac dimensions than Black African and Caucasian athletes. There was no significant difference between the frequency of an uncommon and training-unrelated ECG between Arabic and Caucasian athletes. Therefore, the use of ESC guidelines for the interpretation of an athlete's ECG is clinically relevant and acceptable for use within Arabic athletes.

Do big athletes have big hearts? Impact of extreme anthropometry upon cardiac hypertrophy in professional male athletes.

AIM: Differentiating physiological cardiac hypertrophy from pathology is challenging when the athlete presents with extreme anthropometry. While upper normal limits exist for maximal left ventricular (LV) wall thickness (14 mm) and LV internal diameter in diastole (LVIDd, 65 mm), it is unknown if these limits are applicable to athletes with a body surface area (BSA) >2.3 m(2). PURPOSE: To investigate cardiac structure in professional male athletes with a BSA>2.3 m(2), and to assess the validity of established upper normal limits for physiological cardiac hypertrophy. METHODS: 836 asymptomatic athletes without a family history of sudden death underwent ECG and echocardiographic screening. Athletes were grouped according to BSA (Group 1, BSA>2.3 m(2), n=100; Group 2, 2-2.29 m(2), n=244; Group 3, <1.99 m(2), n=492). RESULTS: There was strong linear relationship between BSA and LV dimensions; yet no athlete with a normal ECG presented a maximal wall thickness and LVIDd greater than 13 and 65 mm, respectively. In Group 3 athletes, Black African ethnicity was associated with larger cardiac dimensions than either Caucasian or West Asian ethnicity. Three athletes were diagnosed with a cardiomyopathy (0.4% prevalence); with two athletes presenting a maximal wall thickness >13 mm, but in combination with an abnormal ECG suspicious of an inherited cardiac disease. CONCLUSION: Regardless of extreme anthropometry, established upper limits for physiological cardiac hypertrophy of 14 mm for maximal wall thickness and 65 mm for LVIDd are clinically appropriate for all athletes. However, the abnormal ECG is key to diagnosis and guides follow-up, particularly when cardiac dimensions are within accepted limits.