Athletes’ ECGs: inverted T waves are uncommon, but their risk remains uncertain

A synthesis of 115 studies

The researchers included 115 studies, involving a total of 258,954 people, from 4,509 articles identified. The review examined the prevalence of T-wave inversions and underlying cardiac abnormalities in athletes across different sports, sexes and ethnic groups.

The synthesis used a statistical model designed to account for differences between studies. Analyses by age, sex, ethnicity and diagnostic criteria were planned. Despite this approach, the authors report substantial heterogeneity: results varied considerably from one study to another.

A finding that is more common in athletes

Among athletes over 16, the overall prevalence of T-wave inversions was 4% when international criteria were used. It was higher among Black athletes.

Compared with non-athletes, the prevalence ratio was 1.49, with a 95% confidence interval ranging from 1.13 to 1.97. This comparison concerns the prevalence of an ECG finding, not cardiovascular events. The abstract does not provide the absolute prevalence in the two groups for this comparison.

A finding that is not enough to establish a diagnosis

According to the authors, T-wave inversion may reflect exercise-related ventricular remodeling. However, this possible physiological explanation does not rule out structural heart disease: they emphasize the need for a thorough evaluation.

Among athletes with these inversions, the prevalence of cardiomyopathy diagnoses varied widely. It was below 1% in most studies, but not necessarily in all of them. This result therefore does not guarantee that an individual is free of disease.

Prognosis remains difficult to establish

Acute cardiovascular events were uncommon in most studies. However, their rarity, limited statistical power and differences between studies prevent a robust estimate of the risk associated with T-wave inversions.

The useful distinction is therefore this: an unusual ECG finding does not automatically mean disease, but its relative frequency in athletes does not justify dismissing it. This meta-analysis does not provide a rule for deciding on your own whether to continue or stop training.

What we can take away

T-wave inversions are uncommon in athletes and do not always indicate cardiomyopathy. However, interpreting them requires an evaluation, as the cardiovascular risk remains uncertain.