Anterior T wave inversions may be a benign variant in a young asian population

Abstract Background Electrocardiographic (ECG) anterior T wave inversions (ATWI) reflect repolarisation changes that may indicate underlying cardiomyopathy, specifically arrhythmogenic right ventricular cardiomyopathy (ARVC) or dilated cardiomyopathy (DCM). However, ATWI up to V3 and up to V4 are also considered physiological in athletes 16 years old or athletes of African/Afro-Caribbean descent respectively, especially if characteristic ECG repolarisation morphologies are observed. There is limited data on the significance of ATWI and repolarisation patterns in Asians. Purpose To describe ATWI and repolarisation patterns, and their correlation with cardiac pathologies in young Asian males from a population-wide screening cohort. Methods From January 2018 to October 2023, data were prospectively collected from all conscripted Singaporean males during a standardised pre-enlistment screening comprising health questionnaires, physical examinations and ECG. Irrespective of athletic ability, individuals with TWI ≥1mm in ≥2 contiguous anterior leads (V2-4) were referred for transthoracic echocardiography (TTE), cardiac magnetic resonance imaging (CMR), and other tests as needed. Those with concurrent right bundle branch block, pre-excitation or long QT syndrome were excluded. Results In our cohort of 145,000 males aged 16-21 years (median: 17.5), the prevalence of ATWI was 0.08% (n=115). 108 males completed work-up (Figure), where almost all underwent either rest or stress CMR (n=105; 97.2%). No cases of ARVC or DCM were identified. Attributable structural pathologies – those which plausibly explain the presence of ATWI – were found in 16 (14.8%) patients, 12 of whom had pectus excavatum (Haller index: range 3.1-9.0). Other pathologies included previous myocarditis (n=2, of whom 1 also had pectus excavatum), partial anomalous pulmonary venous connection (n=2) and hypertensive heart disease (n=1). No attributable structural pathologies were detected in 92 (85.2%) patients, although 9 had incidental findings. Most patients had ATWI confined to leads V2-3 (74.1%), with a median average and maximum TWI depth of -1.0 and -2.0 mm respectively (Table). J-point elevation of ≥1mm in ≥1 leads was seen in 61 (56.5%) patients and the most common ST segment morphology was ascending-convex (52.6% of all leads with ATWI), although a combination of both criteria as seen in Black athletes was uncommon (7.0% of all leads with ATWI). Cohort follow-up was complete over the 6-year study period and none of the patients displayed new signs or symptoms of cardiomyopathy. Conclusion In this unselected young Asian male cohort, ATWI prevalence was 0.08%. No ARVC or DCM cases were detected, and majority (85.2%) had no attributable structural pathology. This may suggest benign ethnic variations in repolarisation, or possibly a persistent juvenile pattern in our cohort. More data is required to delineate specific ECG repolarisation patterns that can be considered benign in Asians.Figure Table