Interpreting ECGs in Ethiopian Athletes: Do International Criteria Apply? A Case Series

We present 3 cases of Ethiopian endurance athletes with electrocardiographic patterns resembling the historically described "Black athlete" ECG phenotype. Two athletes presented with symptoms-palpitations and presyncope-and were evaluated in emergency settings. Their ECGs showed T-wave inversions and ST-segment elevation in right precordial leads. Comprehensive workup, including imaging and stress testing, excluded structural or arrhythmic pathology. The third case involved an asymptomatic female marathon runner undergoing routine screening, with similar ECG findings. Longitudinal follow-up confirmed a physiological basis. These cases illustrate the phenotypic overlap between Ethiopian athletes and ECG patterns historically attributed to athletes of African descent, despite limited data validating such patterns in specific subpopulations. The findings underscore limitations of race-based ECG interpretation and highlight the need for more inclusive, phenotype-driven research in sports cardiology to improve accuracy and reduce misclassification. This case series supports the consideration of broader population diversity in developing athlete ECG criteria.