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Can anterior T-Wave inversion be considered normal in young white individuals?

Comment by Luis Serratosa, EAPC Sports Cardiology Section

Sports Cardiology

This study from the group of St. George’s University in London provides new evidence that will help to further improve the specificity of the ECG interpretation standards, while maintaining the accuracy to detect potentially life threatening cardiomyopathies.

There is general agreement that T-wave inversion (TWI) in the inferior or lateral leads in young individuals warrants further investigation for cardiac disease and that anterior T-wave inversion (ATWI), defined as negative T-waves in >2 contiguous anterior leads (V1-V4), in adolescent athletes and black adult athletes is a benign variant. On the other hand, ATWI in white young adults may raise suspicion of cardiomyopathy, specifically arrhythmogenic right ventricular cardiomyopathy (ARVC).

This study of almost 15,000 apparently young (16 to 35 yrs of age) white adults, including 4,720 women and almost 3,000 athletes, showed that ATWI beyond V1 was present in only 2.3% of individuals and that this prevalence fell to just 0.5% beyond V2 (1.2% of women and 0.2% of men). ATWI was more common in women than in men (4.3% vs. 1.4%) and more common among athletes than in nonathletes (3.5% vs. 2.0%), particularly those engaging in >15 h/week of exercise. Also to be mentioned is that no one with ATWI fulfilled diagnostic criteria for ARVC after further evaluation or experienced an adverse event during a mean follow-up of 23.1 ± 12.2 months.

The authors conclude that their results provide support for the consensus based Seattle recommendations which suggest that ATWI confined to V1-V2 in asymptomatic white athletes without family history of cardiomyopathy or premature SCD may be considered a normal pattern, but white individuals with TWI extending beyond V2 require further evaluation, particularly when preceded by J point or ST segment depression.

As mentioned by the authors among the study limitations, the follow-up period was short and there was no familial evaluation, so no certainty exists whether ATWI could be preceding the development of ARVC in some individuals. Given the potentially sinister consequences of false negative tests with regard to ARVC in particular, there might still be certain concern about ATWI confined to V1 to V2 being a manifestation of ARVC. In this regard, a previous study of the same group of research found that only 6% of their cohort of 35 probands with ARVC showed ATWI in V1 and V2 alone. All of them had symptoms or other electrical features diagnostic of ARVC (1).

Even if true that more robust data might be necessary to confirm the findings of the present study, it definitely represents another important step in improving the accuracy of athletes ECG interpretation.


Note: 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.


1.  Clinical differentiation between physiological remodeling and arrhythmogenic right ventricular cardiomyopathy in athletes with marked electrocardiographic repolarization anomalies. ,Zaidi A, Sheikh N, Jongman JK et al., J Am Coll Cardiol. 2015 Jun 30;65(25):2702-11.
2. Anterior T-Wave Inversion in Young White Athletes and Nonathletes. Prevalence and Significance
Malhotra A, Dhutia H, Gati S et al., J Am Coll Cardiol. 2017 Jan 3; 69(1):1-9.