Prevalence and significance of anterior T-wave inversion in elite football players in the United Kingdom
Key result
Black ethnicity is linked to ~8-fold higher anterior T-wave inversion prevalence without major cardiac pathology.
- P<0.001
- n=10,955
Population
10,955 professional football players in the UK undergoing pre-participation screening, comprising 9,009…
Design
Cross-sectional
Authors
Discussion
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The findings of this study are clinically significant, because they support a more ethnicity-informed and evidence-based interpretation of athlete ECGs, helping clinicians reduce potentially unnecessary investigations, anxiety, sporting restrictions, and potential disqualification in Black athletes where ATWI can occur commonly in the absence of structural heart disease. Conversely, the relative rarity of ATWI in non-Black athletes, alongside the identification of arrhythmogenic cardiomyopathy in this group, reinforces why further evaluation remains appropriate in non-Black individuals. More broadly for cardiology, the study highlights the importance of contextual and population-specific ECG interpretation rather than applying a 'one-size-fits-all' approach, which has implications not only for athlete screening but also for precision cardiovascular medicine and reduction of diagnostic inequities across ethnic groups.”
“In this large cohort, we observed substantial heterogeneity within players of Black ethnicity. West and Central African players manifested more pronounced repolarisation abnormalities and structural remodelling, while major cardiac conditions within the Black player cohort also varied by ancestral origin, with the greatest burden observed in players of West African origin. These findings suggest that treating athletes of Black ethnicity as a single group may oversimplify clinically meaningful differences in screening outcomes. Further work is required to determine whether incorporating ancestral origin into screening strategies can improve the precision and efficiency of cardiovascular evaluation.”
Implication
May support benign ECG interpretation in elite athlete screening; extends observations but leaves open need for prospective validation.
Key Points
- To evaluate the prevalence and clinical significance of anterior T-wave inversion and athlete anterior repolarisation patterns among elite Black and non-Black football players.
- Conducted pre-participation cardiovascular screening on 10,955 elite football players in the UK (9,009 males, 1,946 females; 2,372 Black, 8,583 non-Black) between 2017 and 2024.
- Evaluated athletes using a health questionnaire, 12-lead ECG, and echocardiogram, defining anterior T-wave inversion (ATWI) as inversion confined to leads V1-V3 or V1-V4.
- ATWI was present in 255 (10.8%) Black athletes compared with 115 (1.3%) non-Black athletes (p<0.001), and the specific athlete repolarisation pattern appeared in 245 (10.3%) versus 42 (0.5%) athletes (p<0.001).
- ATWI was more frequent in Black males than females (251 [11.0%] vs 4 [4.3%]; p=0.04), whereas in non-Black athletes it was less frequent in males than females (81 [1.2%] vs 34 [1.8%]; p=0.04).
- Zero Black athletes with ATWI showed major cardiac pathology, while one (0.9%) non-Black athlete presenting with ATWI and isoelectric ST-segments extending to lead V4 was diagnosed with arrhythmogenic cardiomyopathy.
Study Design
Type
Cross-Sectional (n=10,955)
Structured PICO
P
Population
10,955 professional football players (17.8% female) in the UK undergoing pre-participation screening to assess the prevalence and significance of anterior T-wave inversion.
O
Outcome
Prevalence of anterior T-wave inversion (ATWI) and the 'athlete anterior repolarisation pattern', and their association with major cardiac pathology.
Main Result
Absolute Event Rate: 10.8% vs 1.3%
p-value: p=<0.001
The athlete anterior repolarisation pattern is significantly more common in Black athletes but is not associated with major cardiac pathology in either Black or non-Black athletes, supporting its benign nature in elite football players.
Cite This Study
Yamagata et al. (2026) conducted a cross-sectional in Anterior T-wave inversion (n=10,955). Black ethnicity vs. Non-Black ethnicity was evaluated on Prevalence of anterior T-wave inversion (ATWI) (p=<0.001). Black ethnicity was associated with a higher prevalence of anterior T-wave inversion compared to non-Black ethnicity (10.8% vs 1.3%, p<0.001), without association to major cardiac pathology.