BACKGROUND: Preparticipation screening of athletes may prevent sudden cardiac deaths. The issue is complicated by training-induced electrical and structural cc:irdiac adaptations presenting a diagnostic 'grey-zone' with cardiomyopathies. Athletic left ventricular remodeling, of greatest magnitude in black athletes, has been extensively studied. Training-induced right ventricular (RV) adaptation has been neglected, even though healthy athletes may exhibit features overlapping with arrhythmogenic right ventricular cardiomyopathy (ARVC). OBJECTIVES: 1) To characterise RV adaptation in athletes. 2) To assess the impact of black ethnicity on athletic RV remodeling. 3) To establish the significance of electrocardiographic RV hypertrophy in athletes. 4) To determine discriminators between physiology and pathology in athletes with ECG features of ARVC. METHODOLOGY: Athletes (n=754), non-athletic controls (n=257), ARVC patients (n=68), and pulmonary hypertension patients (n=30) were investigated using ECG and echocardiography, with attention to RV parameters. Subjects exhibiting features compatible with RV pathology were evaluated further with cardiac magnetic resonance, exercise testing, Holter monitor, and signal-averaged ECG. RES ULTS: 1) RV dimensions were -15% greater in athletes than controls, with preserved functional indices. 2) RV structural remodeling was of similar magnitude in black and white athletes, although frequent T-wave inversion in blacks created greater diagnostic overlap with ARVC (3 .0% vs. 0.3%). 3) Electrocardiographic RV hypertrophy was common in athletes (11.8%), but was not indicative of pathology. 4) In athletes exhibiting T-wave inversion, diagnostic criteria for ARVC exhibited low specificity. Comprehensive assessment was able to differentiate borderline cases. CONCLUSIONS: Physiological RV remodeling is common in athletes: reference values derived from sedentary individuals should therefore not be applied. The potential for erroneous diagnosis of ARVC is considerably greater in black athletes. ECG criteria for RV hypertrophy are also common in athletes, and should not prompt further evaluation if observed in isolation. Clinical assessment using simple techniques can differentiate physiology from pathology in borderline cases.

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