T wave inversions in athletes: A variety of scenarios

•Intense athletic exercise is associated with repolarization changes that affect the ST-segment and T-wave morphology.•Correct electrocardiogram (ECG) interpretation is crucial to avoid an erroneous diagnosis and understanding the effects of ethnicity, gender and age is important to our comprehension of the athlete's ECG.•In order to reduce the false-positive rates with contemporary ECG criteria, the sports cardiology bodies must strive to better distinguish benign ECGs from abnormal ones.•T-wave inversion preceded by convex ST-elevation in leads V1–V4 in black athletes may represent ethnic variation which is exaggerated by exercise.

Athletic intensive exercise is associated with repolarization changes affecting the ST-segment and T-wave morphology. The prevalence and distribution of these alterations are influenced by several demographic factors. One of the most challenging conundrums for both the cardiologist and the sports medicine physician is the correct interpretation of these repolarization changes to prevent an erroneous diagnosis with potentially serious consequences. A 12-lead electrocardiogram (ECG) demonstrating inverted T-waves may represent the first and only sign of such inherited heart muscle diseases, and may precede the detection of any structural changes in the heart, however, T-wave inversion in leads V1–V4 in black athletes may represent ethnic variation which is exaggerated by exercise.