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Is it possible to differentiate athlete’s physiological from pathological anterior T-wave inversion?

Comment by Luis Serratosa, EACPR Sports Cardiology Section

Sports Cardiology

Distinguishing the physiological adaptations of the athlete’s heart from some of the cardiomyopathies most frequently associated with exercise related sudden cardiac death in young athletes, continues to be challenging. The differential diagnosis may prove particularly difficult when dealing with athletes with anterior (V1-V4) T-wave inversion (TWI) in the resting 12-lead electrocardiogram (ECG). Anterior TWI may be present in 2-4% of patients with hypertrophic cardiomyopathy (HCM) and up to 80% of patients with arrhythmogenic ventricular cardiomyopathy (ARCV), but also in a significant proportion of healthy athletes of different ethnicities (up to 8% of white endurance athletes and 13% of African/Caribbean black athletes).

In order to identify repolarization features that may help to differentiate between physiological and pathological anterior TWI, the authors of the present study analysed the ECGs of healthy athletes and patients with HCM and ARVC of different ethnicities (white and black), who showed anterior TWI. The study population came from three collaborative centres in Italy (Padova and Rome) and the UK (London).

The main conclusion of the study is that the combination of J-point elevation (≥ 1 mm) and anterior TWI confined to V1-V4 may be a normal variant in both African/Caribbean black and white athletes. These combined criteria allowed to halve the number of false positive results in athletes with anterior TWI and therefore demonstrates that ECG analysis of J-point amplitude and distribution of TWI in the precordial leads may significantly reduce the number of healthy athletes referred for unnecessary and expensive clinical investigations to exclude cardiomyopathy.

Conversely and also according to the authors proposal, anterior TWI beyond V4 with or without J-point elevation (J point < 1 mm) should not be considered as a physiological adaptation to physical exercise and requires of a comprehensive clinical work-up, including cardiac magnetic resonance, before excluding the diagnosis of inherited cardiomyopathy.

If confirmed with larger cohorts of patients and athletes with HCM and ARVC, the findings of the present study should be used for future updates of the athlete’s ECG interpretation criteria.


The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.