Prevalence and cardiac outcomes of T wave inversions in high school athletes: an analysis of 15 years of preparticipation screening ECGs

Objective To characterise the prevalence, distribution pattern and clinical relevance of T wave inversion (TWI) on a screening preparticipation 12-lead ECG in high school athletes. Methods A retrospective cohort study analysed ECGs from athletes screened between 2010 and 2025 during a preparticipation event. Athletes with TWI in ≥2 contiguous leads were included. Longitudinal cardiac outcomes were assessed via electronic health records, semistructured interviews and extensive media and death registries review. Results Among 16 893 high school athletes screened (mean age 15.3±1.1 years), 61 (0.36%) demonstrated TWI in ≥2 consecutive leads, representing 20.2% of those flagged with abnormal ECGs. The majority of athletes with TWI were male (n=51, 83.6%), with 46 (75.4%) in black and 14 (23.0%) in non-black male athletes. Anterior+lateral + inferior TWI was the most frequent pattern (n=17, 27.9%). Four male athletes were identified with confirmed or presumed hypertrophic cardiomyopathy (HCM); two identified after screening, one identified 5 years after screening and one lost to follow-up who did not complete the diagnostic evaluation until after a cardiac arrest 2 years later. Conclusion Abnormal TWI was rare in this large US adolescent athlete cohort, with higher prevalence among black males. All confirmed or presumed cases of HCM occurred in athletes with inferior+lateral TWI, underscoring the importance of a comprehensive assessment and longitudinal surveillance in athletes with this ECG phenotype.