Prevalence and significance of T-wave inversion in Arab and Black paediatric athletes: Should anterior T-wave inversion interpretation be governed by biological or chronological age?

Abstract

Background: International electrocardiographic (ECG) recommendations regard anterior Twave-inversion (ATWI) in athletes <16 years to be normal. Design: Identify the prevalence, distribution, and determinants of TWI by ethnicity, chronological and biological age within paediatric athletes. Secondly, establish diagnostic accuracy of international ECG recommendations against refinement within athletes who present ECG variants isolated to ATWI (V1-V4) using receiver operator curve (ROC) analysis. Clinical context was calculated using Bayesian analysis. Methods: 418 Arab and 314 black male athletes (11-18 years) were evaluated by ECG, echocardiogram and biological age (via radiological x-ray) assessment. Results: 116 (15.8%) athletes presented ATWI (V1-V4), of which 96 (82.8%) were ECG variants isolated to ATWI. 91 (12.4%) athletes presented ATWI confined to V1-V3, with prevalence predicted by black ethnicity (odds ratio (OR) 2.2; 95% CI 1.3-3.5) and biological age <16 years (OR 2.0; 95% CI 1.2-3.3). Of the 96 with ATWI (V1-V4) observed in the absence of other ECG findings considered to be abnormal as per international recommendations for ECG interpretation in athletes, diagnostic accuracy was 'fail' (0.47 95% CI 0.00-1.00) for international recommendations and 'excellent' (0.97 95% CI 0.92-1.00), when governed by biological age <16 years, providing a positive (+LR) and negative (-LR) likelihood ratio of 15.8 (95% CI 1.8-28.1) and 0.0 (95% CI 0.0-0.8), respectively. Conclusion: Interpretation of ECG variants isolated to ATWI (V1-V4) using international recommendations (chronological age <16 years), warrants caution, but governance by biological age yielded an 'excellent' diagnostic accuracy. In clinical context, the 'chance' of detecting cardiac pathology within a paediatric male athlete presenting ATWI in the absence of other ECG findings considered to be abnormal as per international recommendations for ECG interpretation in athletes (+LR=15.8), was 14.4%, whereas a negative ECG (-LR=0.0) was 0%.

Interpretation of T‐wave inversion in physiological and pathological conditions: Current state and future perspectives

“…and reported that 15.8% presented anterior TWI, in the majority of cases confined to leads V1 to V3. 33 In this study, the prevalence of anterior TWI and of Jt elevation was higher in Arabic athletes aged <16 years and in black athletes. Of notice, in three black athletes, a cardiac disease was diagnosed; in these cases, TWI in leads V1 to V4 was associated with other abnormal features, such as lateral TWI, Q waves, or wide QRS.…”

T-wave inversion in young athletes: Should we check their bones or their identity card? The quest for precision medicine

“…Overall, McClean and collaborators have opened a door to improve the predictive power and accuracy of current ECG criteria, particularly in children. 8 Nevertheless, applicability in clinical practice still needs to be established. Chronological age is easily assessed in most individuals but the maturity stage (i.e.…”

“…As McClean and collaborators suggest, looking at bones may better discriminate the significance of TWI in young individuals than checking an identity card for their chronological age. 8…”

“…Third, if the biological age for both Arab and black young athletes is older than their chronological age, as reported by McClean and collaborators, 8 one wonders whether this reflects the competitive advantage enjoyed by the most physically mature athletes over their 'biologically younger' chronological peers. The results suggest that biological age assessment could, potentially, be used to better stratify individuals at the extremes of normality (e.g.…”

“…7 In the present issue of the European Journal of Preventive Cardiology, an international collaboration of renowned researchers sheds light on how TWI should be interpreted in young athletes. 8 In 732 Arab and black athletes aged 11-18 years who underwent pre-participation screening including echocardiography, the presence of TWI in right precordial leads was recorded. The biological age of each young athlete was estimated from left-hand wrist radiological imaging.…”