Repolarization abnormality in athletes is risk factor for cardiomyopathy

Clinical Question

Do repolarization abnormalities among athletes indicate a risk for developing structural heart disease?

Bottom Line

Repolarization abnormalities (inverted T waves >= 2 mm in depth in at least 3 leads other than lead III) indicate an increased risk for the subsequent development of structural heart disease (most commonly: hypertrophic cardiomyopathy). Athletes with these findings on electrocardiogram (ECG) should have an echocardiogram and be monitored closely. (LOE = 3b)


Pelliccia A, Di Paolo FM, Quattrini FM, et al. Outcomes in athletes with marked ECG repolarization abnormalities. N Engl J Med 2008;358(2):152-61.  [PMID:18184960]

Study Design





Outpatient (specialty)


By law, competitive athletes in Italy must undergo a cardiac evaluation that includes a history and physical, an ECG, and a 2D echocardiogram. In this study, the researchers looked for all ECGs that showed evidence of repolarization abnormalities, defined as inverted T waves >= 2 mm in depth in at least 3 leads other than lead III and predominantly occurring in the anterior and lateral precordial leads V2 - V6. They matched these patients with athletes who had normal ECGs. Of 12,550 athletes screened, 123 had repolarization abnormalities and 39 had structural heart disease at the time of presentation, most frequently hypertrophic cardiomyopathy (they were excluded from further analysis). Of the 84 with no structural heart disease at the time of presentation, 3 were lost to follow-up, leaving 81 for the final cohort. Of these, 5 (6%) were eventually diagnosed with cardiomyopathy, 6 (7%) with other cardiovascular disorder, and 70 (87%) developed no cardiovascular disease during the 9-year follow-up period. Two athletes who developed cardiomyopathy suffered cardiac arrest (2.4%) and 1 of them died. Of the 229 control patients, only 4 (1.7%) developed a cardiovascular disorder and none suffered cardiomyopathy or cardiac arrest.