T wave inversion TWI in the lateral or inferolateral leads is seen commonly in HCM (figures 1–3). In a series of asymptomatic patients ≤35 years old with HCM confirmed by cardiac MRI, 62% exhibited TWI.21 Similarly, in patients with a positive HCM genetic test and overt morphological HCM, 54% demonstrate TWI.22 In black patients with HCM, TWI occurs more commonly in the lateral leads (77%) and less frequently in the inferior leads (2%).23 in depth in two or more leads V2–V6, II and aVF, or I and aVL (excludes leads III, aVR and V1). Deep TWI in the midprecordial to lateral precordial leads (V4–V6) should raise the possibility of apical HCM. In healthy athletes, TWI in the lateral or inferior leads is uncommon. TWI beyond V2 is a rare abnormality found in only 0.1% of Caucasian adolescent athletes older than 16 years.24 TWI in the lateral or inferolateral leads is reported in 2% of athletes.25 TWI in the lateral or inferior leads is also about 2%.26 In Caucasian elite athletes, the prevalence of However, TWI is more common in black athletes of AfricanCaribbean descent (hereto referred to as ‘black/African’ athletes). TWI in the lateral or inferior leads is reported in 8–10% of black/African athletes.23 27 Repolarisation variant in black/African athletes TWI in the anterior precordial leads should be distinguished from TWI in the lateral or inferior leads in black/African athletes. TWI in the anterior precordial leads may be part of a normal variant pattern of repolarisation in black/ African athletes consisting of convex (‘dome’ shaped) ST segment elevation followed by TWI in V1–V4 (figure 4). On the basis of current data, TWI preceded by ST segment elevation are present in the anterior precordial leads in up to 13% of black/African athletes and do not require further assessment in the absence of symptoms, positive family history or abnormal physical examination. 23 27 However, TWI in the lateral or inferolateral leads (V5–V6, I and aVL, II and aVF), regardless of ethnicity, is considered abnormal and requires additional testing to rule out HCM (figures 1–3). Juvenile pattern of TWI TWI in the anterior precordial leads in younger, prepubertal athletes often reflects a persistent juvenile pattern and requires careful interpretation. In Caucasian adolescent athletes, anterior precordial TWI extending beyond V2 was present in 1.2% of athletes <16 years but only 0.1% of athleAbnormal TWI is defined as >1 mm Figure 1. Abnormal ECG in a patient with hypertrophic cardiomyopathy. Note the T wave inversion and ST depression in the inferolateral leads (arrows). In a college athletic population of mixed ethnicity, Figure 2. Markedly abnormal ECG in a patient with hypertrophic cardiomyopathy. Note deep T wave inversion and ST depression in the inferolateral leads. Figure 3. Markedly abnormal ECG in a patient with hypertrophic cardiomyopathy. Note the deep T wave inversions in the inferolateral leads (V4–V6, I and aVL, II and aVF). This ECG pattern may represent apical hypertrophic cardiomyopathy which is not adequately evaluated by echocardiography. Cardiac MRI is recommended. nummer 3 | juli 2013 | Sport & Geneeskunde 29 Pagina 28
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