Ethnicity-specific 12-lead resting ECG patterns in brazilian female professional football players: correlation with cardiac imaging in a national multicenter study

Abstract Background Sex and ethnicity are key factors in interpreting the athlete's 12-Lead Resting (ECG). However, comprehensive data on abnormal ECG findings and their correlation with cardiac imaging in a multi-ethnic cohort of Brazilian professional female football players (BPFFP) is scarce. Objective To define the prevalence of abnormal ECG patterns and their association with structural heart disease, as assessed by transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR), across White, Mixed-race, and Black BPFFP. Methods From 2010 to 2025, 1,070 BPFFP (338 White, 356 Mixed-race, 376 Black) from 29 professional clubs underwent pre-participation screening. All athletes with abnormal ECGs underwent TTE; CMR was performed based on TTE findings or clinical suspicion. Results The prevalence of an abnormal ECG was low (2.9%, n=31). Among these, TTE was normal in 30 athletes (97%). Key abnormal findings included: Isolated inferior T-wave inversion (TWI): 0.9%; Combined inferolateral TWI: 0.8%; Wolff-Parkinson-White pattern: 0.3% (n=3, distributed across ethnicities); ST-segment depression: 0.3% (n=3) Notably, one Black athlete with inferolateral TWI and ST-segment depression was found to have apical hypertrophic cardiomyopathy, confirmed by reduced global longitudinal strain on TTE and subsequent CMR. No other ECG abnormalities were associated with structural disease. Conclusions In this large, ethnically diverse cohort of BPFFP, abnormal ECG findings were uncommon. Critically, while the vast majority of these findings were benign, the presence of inferolateral TWI identified a case of apical hypertrophic cardiomyopathy. This underscores that specific, high-risk ECG patterns in female athletes warrant comprehensive imaging evaluation to exclude underlying pathology (Support CNPq).