A worrying ECG pattern was rare in screened high-schoolers — but not meaningless

Whether to add an electrocardiogram (ECG) to the physical exam young athletes get before a season is one of the longest-running disputes in sports medicine. A study published in the British Journal of Sports Medicine on 3 September does not resolve it, but it puts a number on one of the abnormalities that most concerns screeners: T-wave inversion (TWI) [s1].

The finding

The researchers analysed ECGs from high school athletes screened at a preparticipation event between 2010 and 2025, including anyone with T-wave inversion in two or more contiguous leads [s1]. Among 16,893 athletes screened, with a mean age of 15.3±1.1 years, 61 (0.36%) had this pattern — representing 20.2% of the athletes whose ECGs were flagged as abnormal [s1].

T-wave inversion is one of the patterns that international athlete ECG criteria treat as potentially abnormal rather than a normal training adaptation, precisely because it can be the surface trace of an underlying cardiomyopathy [s2]. The value of a screening study is in what those flagged athletes turned out to have.

Who had it, and what it meant

The pattern was concentrated in specific groups. Of the 61 athletes with TWI, 51 (83.6%) were male [s1]. Among the male athletes, 46 (75.4%) were black and 14 (23.0%) were non-black — a distribution consistent with prior evidence that some anterior T-wave inversion patterns are more common in athletes of African or Afro-Caribbean ancestry, which complicates interpretation [s1]. The most frequent overall pattern was combined anterior, lateral and inferior TWI (17 athletes, 27.9%) [s1].

To find out whether the pattern mattered, the researchers followed these athletes through electronic health records, semistructured interviews and a review of media and death registries [s1]. Four male athletes were identified with confirmed or presumed hypertrophic cardiomyopathy (HCM) — the heart-muscle disorder that is among the leading causes of sudden cardiac death in young athletes [s1]. Two were identified through the screening itself, one was diagnosed five years afterwards, and one was lost to follow-up without completing the diagnostic workup [s1].

How to read this

Four cardiomyopathy cases out of 16,893 screened athletes is a small absolute number, and it is exactly the tension at the heart of the screening debate. On one hand, T-wave inversion was rare and, in most of the athletes who had it, did not resolve into a dangerous diagnosis — which means most flagged athletes underwent further evaluation, cost and anxiety without a disease being found. On the other, the pattern did flag real, potentially lethal disease in a handful of teenagers, including one caught only years later and one who was never fully worked up.

The study is a single-centre retrospective cohort built from one screening programme, and its outcome ascertainment — interviews, records and registry searches — is thorough but imperfect; an athlete who moved away or was never diagnosed could be missed. It cannot tell you whether screening this population lowered the death rate, because it has no comparison group of unscreened athletes. What it establishes is a prevalence figure and a yield: how often the pattern appears, in whom, and how often it tracked to a diagnosis that screening exists to catch.

That is the kind of denominator the screening argument has often lacked. It does not tell a reader or a programme what to do — the trade-off between catching rare disease and over-investigating healthy hearts is a value judgement as much as a medical one — but it makes the trade-off concrete.

The wider debate this feeds into is whether to add an ECG to preparticipation screening at all. Some countries and sporting bodies mandate it; much of US practice instead relies on history and physical examination, arguing that ECG screening generates false positives and downstream testing without clear evidence of lives saved. A prevalence-and-yield study like this one does not settle that argument, because it has no unscreened comparison group and cannot measure deaths averted [s1]. What it supplies is the raw material the argument needs: how common a flagged pattern is, in whom, and how often it tracked to a diagnosis screening exists to catch [s1]. Interpreting T-wave inversion also depends on context such as ancestry, which the international athlete ECG criteria explicitly build in [s2].

Sources

• Prevalence and cardiac outcomes of T wave inversions in high school athletes — British Journal of Sports Medicine, 2026-09-03
• International criteria for electrocardiographic interpretation in athletes — British Journal of Sports Medicine, 2017