Empirical Classification of T-Wave Inversion Patterns as Lower Risk or Higher Risk in Black Adults: A Wall-Based...

T-wave inversion (TWI) in Black adults is interpreted through criteria derived from White populations or competitive athletes, never tested with outcome data in nonathletic community adults. The aims of the study were to classify TWI patterns as lower risk or higher risk using lead-specific outcome thresholds and derive a race-specific reference from a healthy subcohort.

We analyzed 3,514 Black adults from the Jackson Heart Study Exam 1 (2000-2004). A wall-based system classified higher risk TWI as Tnet <-100 µV in lateral, anterior, or inferior leads; benign patterns were isolated V1 and isolated lead III. A healthy subcohort (N = 668) free of hypertension, diabetes, obesity, CKD, coronary disease, heart failure, and left ventricular hypertrophy (LVH) ECG criteria served as reference. Logistic regression assessed cardiometabolic associations; Cox models assessed incident outcomes over median 11.8-year follow-up.

Higher risk TWI was present in 262 (7.5%; healthy: 3.0%) and lower risk patterns in 685 (19.5%). Higher risk TWI independently predicted Hard coronary heart disease (CHD), with an adjusted hazard ratio of 2.47 (95% CI 1.51-4.04), and was associated with hypertension (OR 1.98) and ECG-LVH (OR 3.98). Benign V1 showed inverse associations with diabetes (OR 0.48) and LVH (OR 0.36), with 1 Hard CHD event during follow-up; the higher risk effect was homogeneous across health strata (P-interaction = 0.455). The classic V1-V2-V3 juvenile pattern occurred in 1 of 3,514; V3 inversion carried Hard CHD HR 3.49.

Anterior T-wave inversion in V2, V3, or V4 in nonathletic Black community-dwelling adults is not necessarily a benign signal and should not be assumed to represent a persistent juvenile variant. These data provide the first outcomes-anchored ECG reference for this population.