Anterior T-Wave Inversion in Athletes and Nonathletes

Study Questions:

What is the prevalence and significance of anterior T-wave inversion among young, white athletic and nonathletic adults?


Between 2007 and 2013, 14,646 individuals (4,720 [32%] women) in the United Kingdom, ages 16-35 years, were evaluated with a health questionnaire, physical examination, and 12-lead electrocardiogram (ECG) through the charitable organization Cardiac Risk in the Young. Screening included 2,958 (20.2%) athletes competing at regional, national, or international levels who exercised ≥8 hours per week, and 11,688 (79.8%) nonathletes (≤8 hours of organized physical activity per week). Anterior T-wave inversion was defined as T-wave inversion in ≥2 contiguous anterior leads (V1-V4). Echocardiography was performed among all subjects with anterior T-wave inversion and among some athletes without T-wave inversion; in addition, some subjects with anterior T-wave inversion underwent additional testing including signal-averaged ECG (93%), cardiac magnetic resonance imaging (74%), exercise stress testing (81%), and ambulatory ECG monitoring (87%).


Anterior T-wave inversion was detected in 338 (2.3%) individuals; and was more common in women than men (4.3% vs. 1.4%; p < 0.0001), and among athletes compared with nonathletes (3.5% vs. 2.0%; p < 0.0001). T-wave inversion was predominantly confined to leads V1-V2 (77%). Only 1.2% of women and 0.2% of men exhibited T-wave inversion beyond V2. No one with anterior T-wave inversion fulfilled diagnostic criteria for arrhythmogenic right ventricular cardiomyopathy (ARVC) after further evaluation. During a mean follow-up of 23.1 ± 12.2 months, none of the individuals with anterior T-wave inversion experienced an adverse event.


The authors concluded that anterior T-wave inversion confined to V1-V2 is a normal variant or a physiological phenomenon in asymptomatic white individuals without a relevant family history. Anterior T-wave inversion beyond V2 is rare, particularly in males, and may warrant additional investigation.


ECG anterior T-wave inversion in young white adults raises the possibility of cardiomyopathy, specifically ARVC. The 2010 European consensus recommendations for ECG interpretation in young athletes state that anterior T-wave inversion beyond V1 should warrant further investigation. However, the prevalence of anterior T-wave inversion reported in this large population suggests that, when confined to leads V1-V2, anterior T-wave inversion may be a normal variant or a physiological phenomenon in asymptomatic white individuals without a relevant family history.

Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Sports and Exercise Cardiology, Implantable Devices, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Exercise, Sports and Exercise and ECG and Stress Testing, Sports and Exercise and Imaging

Keywords: Arrhythmias, Cardiac, Heart Failure, Diagnostic Imaging, Sports, Arrhythmogenic Right Ventricular Dysplasia, Athletes, Echocardiography, Electrocardiography, Electrocardiography, Ambulatory, Exercise, Exercise Test, Magnetic Resonance Imaging, Physiological Phenomena

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