Interpretation and management of T wave inversion in athletes. An expert opinion statement of the Italian Society of Sports Cardiology (SICSPORT)

T wave inversion (TWI) on the electrocardiogram (ECG) is a relatively common finding in athletes. It poses a diagnostic challenge, as it can indicate either a benign physiological pattern or an early sign of serious cardiac pathology. This expert opinion statement provides a comprehensive review of the current understanding of TWI in athletes, emphasizing the importance of its localization, associated clinical features, and demographic factors in guiding its interpretation and management. We explore the potential causes of TWI, including physiological adaptations such as the juvenile pattern and training-induced repolarization variants, as well as pathological conditions like cardiomyopathies, ion channel diseases, and other cardiac abnormalities. Additionally, we discuss the implications of TWI in different ECG leads—anterior, inferior, and lateral—and the diagnostic work-up needed to exclude underlying disease. The importance of follow-up in athletes with TWI is highlighted, particularly for young athletes, to monitor the potential development of cardiomyopathy. Finally, we address considerations for sports eligibility in athletes with TWI, stressing the need for a balanced approach that ensures athlete safety without imposing unnecessary restrictions and investigations.