T-wave inversions in athletes: frequency and prognostic significance. A systematic review and meta-analysis

Aim: T-wave inversions (TWI) are a challenging finding in athletes' electrocardiograms. This study aimed to determine the frequency and prognosis of TWI in athletes. Methods: A systematic review and meta-analysis were conducted following PRISMA guidelines and registered in PROSPERO (CRD42023494038). Data sources were PubMed, Scopus, and Web of Science. We included original research articles reporting on the prevalence or underlying substrates of TWI and providing data on athletes participating in any type of sports, sex, or race. Risk of bias was evaluated using the Joanna Briggs Institute Critical Appraisal Tool for Cross-Sectional Studies. Fixed or random-effects models were used depending on heterogeneity. Sensitivity and subgroup analyses (sex, age, ethnicity, diagnostic criteria) were predefined. Results: Of 4,509 articles identified, 115 were selected (258,954 individuals). Substantial heterogeneity was observed among the study results. The global TWI prevalence in athletes > 16 years according to the Seattle criteria was 6% (4%, 1%, and 1% in anterior, inferior, and lateral leads, respectively). Prevalence was higher in Black athletes. TWI was more frequent in athletes than non-athletes (Prevalence ratio=1.49; 95% Confidence Interval: 1.13–1.97). Cardiomyopathy diagnosis among athletes with TWI showed high variability, but in most studies, prevalence was <1%. Acute cardiovascular event incidence was 0 in 16 of 19 studies with clinical follow-up. Conclusions: TWI is more frequent in athletes than non-athletes but remains low overall. While it may reflect physiological exercise related ventricular remodelling, thorough evaluation is essential to exclude structural heart disease. Cardiovascular event incidence in athletes with TWI is very low.