Cardiac Risk Ancestry Plays a Key Role in Cardiac Screening for Elite Footballers

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An observational study of more than 9,000 elite male footballers in England has investigated parameters associated with sudden cardiac death. West and Central African players showed more pronounced ECG abnormalities and structural heart remodelling than other Black subgroups and non Black athletes, with the highest burden of major cardiac conditions observed in those of West African origin.

Ljubljana/Slovenia – Elite footballers of Black ethnicity show important ancestry-related differences in cardiac adaptation. These results were presented recently at ESC Preventive Cardiology 2026, the annual congress of the European Association of Preventive Cardiology (EAPC), a branch of the European Society of Cardiology (ESC).

Presenter Doctor Kentaro Yamagata from the Institute of Sport, Manchester Metropolitan University, United Kingdom, said: “Several studies have reported a higher incidence of sudden cardiac death (SCD) in athletes of Black ethnicity. Athletes of Black ethnicity are typically considered as a single group, despite substantial heterogeneity in ancestral origin. We conducted an analysis of elite male football players, analyzing electrical and structural heart measurements and major cardiac conditions by regional ancestry.”

This observational study, overseen by senior author Professor Aneil Malhotra, was conducted on elite male football (soccer) players aged 16 years or over undergoing mandatory pre-participation cardiovascular screening within the English Football Association programme between 2017 and 2024. Screening included a health questionnaire, 12-lead ECG and echocardiography. Athletes self-identifying as Black were classified by regional ancestry using the United Nations Geoscheme. Clinical outcomes were adjudicated by expert sports cardiologists.

The study included data from 9,024 players: 25.4 % were Black, and 74.6 % were non-Black. Within the Black cohort, the largest subgroup was West African (51.9 %), followed by Caribbean (32.0 %), with smaller numbers from East (7.1 %), Central (4.3 %), North (2.7 %) and South Africa (2.0 %).

Compared with non-Black players, Black players demonstrated a higher prevalence of abnormal ECG characteristics and structural changes. However, these findings were not uniformly distributed across Black regional subgroups. Players of Central and West African origin exhibited the greatest burden of electrical abnormalities and structural remodelling, whereas players of North African origin showed prevalences closer to those observed in non-Black players. For example, ECG T-wave inversions (TWI), which can be a marker of heart muscle dysfunction, were highest in players from Central Africa (10.1 %) and West Africa (6.4 %), intermediate in those from the Caribbean (4.5 %), East Africa (4.3 %) and South Africa (4.3 %), and lowest in North African (1.6 %) and non-Black (2.2 %) athletes.

Clinically significant cardiac conditions associated with SCD, including hypertrophic cardiomyopathy, were identified in 1.0 % of Black players and 0.4 % of non-Black players (p=0.001). Among Black players, major cardiac conditions occurred most commonly in those of West African origin (1.6 %), followed by Caribbean origin (0.7 %).

Summing up the findings, Doctor Yamagata said: “In this large cohort, we observed substantial heterogeneity within players of Black ethnicity. West and Central African players manifested more pronounced repolarisation abnormalities and structural remodelling, while major cardiac conditions within the Black player cohort also varied by ancestral origin, with the greatest burden observed in players of West African origin. These findings suggest that treating athletes of Black ethnicity as a single group may oversimplify clinically meaningful differences in screening outcomes. Further work is required to determine whether incorporating ancestral origin into screening strategies can improve the precision and efficiency of cardiovascular evaluation.”

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