Anterior T-wave inversion (ATWI), a change seen on an ECG in the leads that look at the front of the heart, was observed nearly nine times more frequently in Black football players than in non-Black players, in an observational cross-sectional study being presented at the British Cardiovascular Society’s annual conference in Manchester. T-wave inversion happens when one part of the ECG tracing, called the T wave, points downwards instead of upwards. The T wave reflects how the heart resets electrically after each heartbeat.
The presence of ATWI in competitive athletes has previously been considered a diagnostic challenge for consulting cardiologists, as although this is usually associated with some benign conditions, it may also be a sign of an underlying cardiomyopathy, a condition which is associated with sudden cardiac death (SCD). Notably, the presence of ATWI associated with another ECG characteristic called convex ST segment elevation in athletes of Black ethnicity has been considered normal, but a cause for concern about possible cardiomyopathy when it comes to non-Black athletes.
The study, the joint effort of researchers from the Manchester Institute of Sport, Hull University Teaching Hospitals, St George’s University of London, international collaborators from Italy and Singapore, and The Football Association, sought to assess how prevalent ATWI was found in professional Black and non-Black football players, and what the significance of this prevalence was.
Of the almost 11,000 football players studied (82.2% male, 17.8% female), 21.7% players were Black, and 78.3% non-Black (divided respectively into 98% White, 2% Asian). All players underwent pre-participation screening as part of the English Football Association programme in 2017-2024, as well as completing a health questionnaire, a 12-lead ECG and a transthoracic echocardiogram – with clinical outcomes assessed by sports cardiologists. A 12-lead ECG is a quick test that uses sticky sensors on the chest to record the heart’s electrical activity and rhythm. A transthoracic echocardiogram is a type of ultrasound scan on the chest to look at the heart’s structure and pumping function.
Dr Rajiv Sankaranarayanan, of the British Cardiovascular Society, said: “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.”
ATWI was defined as a T-wave inversion in ECG leads V1 to V3 or V4, which are the leads that look at the front of the heart.
When it came to prevalence, among the tested, ATWI was more common in male (11%) than female (4.3%) Black football players. Conversely, when it came to non-Black players, ATWI was found more in female players (1.9% of non-Black female players, 1.2% of non-Black male players).
Looking at significance, none of the 251 Black football players diagnosed with ATWI had major cardiac pathology associated with SCD, but one (0.9%) non-Black player demonstrating ATWI with isoelectric ST segment was diagnosed with arrhythmogenic cardiomyopathy. Further, minor cardiac conditions were identified in 1.5% of Black and 1.7% of non-Black players, and no player in this category showed any other ECG changes aside from ATWI. Given the prevalence and significance of ATWI in professional athletes, study authors concluded that “ATWI in non-Black athletes associated with isoelectric ST segment should prompt further investigation because of the risk of underlying cardiomyopathy.”
– ENDS –
Note to editors:
If using this study, please ensure you mention that the study was presented at the British Cardiovascular Society’s Annual Conference.
The conference will be held at Manchester Central from 1 to 3 June 2026, and is attended by UK and international cardiologists and healthcare professionals.
About the BCS
The British Cardiovascular Society is a membership association, with a pivotal role to play in the delivery of cardiovascular health across the UK, supporting and representing all those working in the fields of cardiovascular care and research. We do this through our educational activities, our key roles in the organisation of cardiology training and production of clinical guidelines, and our input into national policy.
We currently have over 3,000 members, including consultant cardiologists, resident cardiologists, nurses, GPs with a special interest in cardiology, non-clinical scientists and technicians.
For further information about the charity, visit britishcardiovascularsociety.org.uk.