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Anterior TWI – No Arrhythmia Risk

February 27, 2017

Short Attention Span Summary

Anterior TWI in V1 and V2 in young white people
Anterior T-wave inversion (TWI) in young white people in leads other than V1 may indicate arrhythmogenic right ventricular cardiomyopathy (ARVC).  But this large study of white people, including many athletes, aged 16-35 with TWI in the anterior leads (most often V1 and V2, with very few beyond V2), found no increase in incidence of ARVC on further evaluation.  Anterior TWI in V1 and V2 appears to be a a normal physiologic variant in normal healthy young white people and are of no concern unless there is a positive family history of arrhythmia.  TWI beyond V2 is rare and may need more workup.  I wondered why only white people were studied, and the authors state, “Because the prevalence of ATWI has been reported in black athletes [and are very common – my comment], controls of both sexes, and the adolescent population, the present study focused on the prevalence and significance of ATWI in a large cohort of apparently healthy white adults including a large proportion of athletes.”

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Anterior TWI in V1 and V2 appears to be a normal variant in young healthy white people, assuming no family history of arrhythmia.


J Am Coll Cardiol. 2017 Jan 3;69(1):1-9. doi: 10.1016/j.jacc.2016.10.044.

Anterior T-Wave Inversion in Young White Athletes and Nonathletes: Prevalence and Significance.

Malhotra A1, Dhutia H1, Gati S1, Yeo TJ1, Dores H2, Bastiaenen R1, Narain R1, Merghani A1, Finocchiaro G1, Sheikh N1, Steriotis A1, Zaidi A1, Millar L1, Behr E1, Tome M1, Papadakis M1, Sharma S3.

Author information:

1Division of Cardiovascular Sciences, St. George’s University of London, United Kingdom.

2Department of Cardiology, Universidade Nova de Lisboa, Hospital das Forças Armadas, Luz Saúde, NOVA Medical School, Lisbon, Portugal.

3Division of Cardiovascular Sciences, St. George’s University of London, United Kingdom. Electronic address: sasharma@sgul.ac.uk.



Anterior T-wave inversion (ATWI) on electrocardiography (ECG) in young white adults raises the possibility of cardiomyopathy, specifically arrhythmogenic right ventricular cardiomyopathy (ARVC). Whereas the 2010 European consensus recommendations for ECG interpretation in young athletes state that ATWI beyond lead V1 warrants further investigation, the prevalence and significance of ATWI have never been reported in a large population of asymptomatic whites.


This study investigated the prevalence and significance of ATWI in a large cohort of young, white adults including athletes.


Individuals 16 to 35 years of age (n = 14,646), including 4,720 females (32%) and 2,958 athletes (20%), were evaluated by using a health questionnaire, physical examination, and 12-lead ECG. ATWI was defined as T-wave inversion in ≥2 contiguous anterior leads (V1 to V4).


ATWI was detected in 338 individuals (2.3%) and was more common in women than in men (4.3% vs. 1.4%, respectively; p < 0.0001) and more common among athletes than in nonathletes (3.5% vs. 2.0%, respectively; p < 0.0001). T-wave inversion was predominantly confined to leads V1 to V2 (77%). Only 1.2% of women and 0.2% of men exhibited ATWI beyond V2. No one with ATWI fulfilled diagnostic criteria for ARVC after further evaluation. During a mean follow-up of 23.1 ± 12.2 months none of the individuals with ATWI experienced an adverse event.


ATWI confined to leads V1 to V2 is a normal variant or physiological phenomenon in asymptomatic white individuals without a relevant family history. ATWI beyond V2 is rare, particularly in men, and may warrant investigation.

Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

PMID: 28057231 [PubMed – in process]

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