Prevalence and significance of anterior T-wave inversion in elite football players in the United Kingdom

Objective The “athlete anterior repolarisation pattern”, characterised by J-point elevation with ascending convex ST-segments and anterior T-wave inversion (ATWI) confined to leads V 1 -V 4 , has been considered a normal finding in athletes of Black ethnicity (African-Caribbean descent). This repolarisation pattern was considered to potentially represent an underlying cardiomyopathy in non-Black athletes although recent studies have challenged this. We assessed the prevalence and significance of ATWI among professional Black and non-Black football players in the UK. Methods Athletes underwent pre-participation screening (2017–2024), including a health questionnaire, a 12-lead ECG and an echocardiogram. ATWI was defined as TWI confined to leads V 1 to V 3 or V 4 . Ethnicity was categorised as Black or non-Black. Results 10 955 athletes were studied, comprising 9009 (82.2%) males and 1946 (17.8%) females. 2372 (21.7%) athletes were of Black ethnicity and 8583 (78.3%) were non-Black. Black athletes were marginally younger (18.3±3.8 vs 19.2±4.7 years; p<0.001). ATWI was observed in 255 (10.8%) Black athletes versus 115 (1.3%) non-Black athletes (p<0.001). ATWI was more common in Black males compared with females (251 (11.0%) vs 4 (4.3%); p=0.04). Among non-Black athletes, ATWI was less common in males (81 (1.2%) males vs 34 (1.8%) females; p=0.04). The “athlete anterior repolarisation pattern” was present in 245 (10.3%) Black athletes and 42 (0.5%) non-Black athletes (p<0.001). None of the Black athletes with ATWI exhibited major cardiac pathology, whereas one (0.9%) non-Black athlete with ATWI and isoelectric ST-segments was diagnosed with arrhythmogenic cardiomyopathy. Conclusion The “athlete anterior repolarisation pattern” was 20 times more common in Black athletes than in non-Black athletes. However, this repolarisation pattern was not associated with major pathology in either Black or non-Black athletes in this UK screening cohort. By contrast, the only cardiomyopathy identified in an athlete with any ATWI occurred in a non-Black athlete with isoelectric ST-segments extending to V 4 .