Beyond Racial Categorization in Sports Cardiology: A Systematic Review of Cardiac Adaptations in Athletes

Background/Objectives: Race-based cardiac screening criteria in sports cardiology, including the "Black athlete's heart" concept, assume biological distinctions that may not reflect physiological reality. This systematic review evaluates whether geographic ancestry provides more clinically relevant predictors of cardiac adaptation than racial categorization. Methods: PubMed was searched (January 2005-July 2025) for studies examining cardiac adaptations in athletes by ethnicity. Data extraction captured demographics, geographic origin, cardiac assessments, and outcomes. Narrative synthesis was employed due to methodological heterogeneity. Results: Forty-seven studies (n = 66,130) revealed substantial within-race heterogeneity. The "Black athlete repolarization variant" prevalence ranged from 1.8% (Brazilian) to 30% (Ghanaian) Black athletes. Left ventricular wall thickness >12 mm (normal <11 mm) occurred in 7.1% of Black versus 0.4% of White athletes, yet varied significantly within Black populations-10.8 ± 1.2 mm in Sub-Saharan versus 9.4 ± 1.1 mm in African-American athletes (p < 0.001). Relative wall thickness ≥0.44 (normal ≤0.42) was presented in 43% of West/Middle African, 23% of East African, and 7% of White athletes. T-wave inversion showed four-fold variation within Black populations (3.6-8.5% West African versus 0.5-2.0% African-American/Caribbean). Current International Criteria demonstrated inequitable specificity: 3.3% false-positive rate in Black versus 1.4% in White athletes. Conclusions: Geographic ancestry explains more cardiac variation than racial categories, supporting contemporary understanding of race as a sociopolitical construct. The persistent diagnostic disparities in ECG screening specificity highlight the need for reform. Transitioning toward protocols incorporating continental origin, anthropometric factors, and social determinants of health-while eliminating terminology like "Black athlete's heart"-represents an important step toward achieving equity in cardiovascular care for diverse athletic populations.