Empirical Classification of T-Wave Inversion Patterns as Lower-risk or Higher-risk in Black Adults: A Wall-Based Prevalence and Outcomes Analysis from the Jackson Heart Study

Background T-wave inversion (TWI) in Black adults is interpreted through criteria derived from White populations or competitive athletes, never tested with outcomes data in non-athletic community adults. Objective To classify TWI patterns as lower-risk or higher-risk using lead-specific outcomes thresholds, and derive a race-specific reference from a healthy subcohort. Methods We analyzed 3,514 Black adults from the Jackson Heart Study Exam 1 (2000-2004). A wall-based system classified higher-risk TWI as Tnet <-100 µV in lateral, anterior, or inferior leads; benign patterns were isolated V1 and isolated lead III. A healthy subcohort (N=668) free of hypertension, diabetes, obesity, CKD, coronary disease, heart failure, and left ventricular hypertrophy (LVH) ECG criteria served as reference. Logistic regression assessed cardiometabolic associations; Cox models assessed incident outcomes over median 11.8-year follow-up. Results Higher-risk TWI was present in 262 (7.5%; healthy: 3.0%); lower-risk patterns in 685 (19.5%). Higher-risk TWI independently predicted Hard coronary heart disease (CHD), with an adjusted hazard ratio of 2.47 (95% CI 1.51-4.04), and was associated with hypertension (OR 1.98) and ECG-LVH (OR 3.98). Benign V1 showed inverse associations with diabetes (OR 0.48) and LVH (OR 0.36), with 1 Hard CHD event during follow-up; the higher-risk effect was homogeneous across health strata (P-interaction=0.455). The classic V1-V2-V3 juvenile pattern occurred in 1 of 3,514; V3 inversion carried Hard CHD HR 3.49. Conclusion Anterior T-wave inversion in V2, V3, or V4 in non-athletic Black community-dwelling adults is not necessarily a benign signal and should not be assumed to represent a persistent juvenile variant. These data provide the first outcomes-anchored ECG reference for this population.