What is the Significance of Pathological T-Wave Inversions in Athletes?

Pathological T-wave inversion (PTWI) has been found to be associated with cardiac pathology in almost half of athletes, with hypertrophic cardiomyopathy (HCM) as the most common cardiac disease identified, according to a study published Nov. 10 in Circulation.

For many athletes, intense physical training has the capability of inducing unique electrical and myocardial adaptations that, while distinct from heart disease, can present diagnostic issues when observed under electrocardiogram (ECG) parameters. One such condition is PTWI, which is rarely observed on an ECG, but is common in patients with certain cardiac diseases.

Seeking to prospectively determine the prevalence of cardiac pathology in athletes presenting with PTWI, and examine the efficacy of CMR in the work–up battery of further examinations, principal study author Frédéric Schnell, MD, Department of Physiology, Rennes University, Rennes, France, and his colleagues found that among 6,372 competitive athletes (n=5,726 male and n=646 female) referred for pre-competitive sporting evaluation, 1,155 (2.4 percent) presented with PTWI. Of the 155 individuals, 55 were further investigated with clinical examination, ECG, echocardiography, exercise testing, 24h Holter ECG and CMR. Results showed that cardiac disease was established in 44.5 percent of athletes, with hypertrophic cardiomyopathy (81 percent) the most common pathology. Echocardiography was deemed abnormal in 53.6 percent of positive cases, while CMR was able to identify an additional 24 athletes with disease. Five athletes (7.2 percent) considered normal on initial presentation later expressed pathology during follow-up.

The authors conclude that while echocardiography was successful in identifying pathology in half of these cases, cardiac magnetic resonance (CMR) must be considered routine in athletes presenting with PTWI with normal echocardiography.

"The study conveys important messages pertinent to all physicians evaluating competitive athletes," write Sanjay Sharma, BSc, MBChB, MD, and Michael Papadakis, MBBS, MD, in a coinciding editorial. "It reaffirms the conclusions of existing literature and recommendations from scientific bodies that all athletes with deep T-wave inversion in ≥two contiguous leads should be investigated comprehensively for an underlying cardiomyopathy. Even if pathology is not identified in the first instance, subsequent surveillance is prudent with repeat evaluation annually, or, sooner should the athlete become symptomatic. Exception to this rule is T-wave inversion in black athletes confined to leads V1-V4, which is considered an ethnic variant of athlete's heart. The study also highlights that CMRI is the investigation of choice in athletes with a high index of suspicion for underlying cardiomyopathy."

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