International sporting organisations are increasingly using ECG-based screening to identify athletes at risk of sudden cardiac death (SCD).1 Since the introduction of athlete ECG interpretation criteria in 2005, numerous modifications have been made to improve their sensitivity and specificity.2 These include a nuanced classification of T-wave inversions (TWI), a potential feature of underlying cardiomyopathy. Since 2013, successive criteria have recommended that TWI confined to the anterior leads (V1–V4) and preceded by J-point elevation and convex ST-segment elevation in black athletes (BA) should be considered a physiological finding within the athlete’s heart spectrum—currently termed the ‘black athlete repolarisation variant’.2 This editorial examines the existing evidence and knowledge gaps in the clinical evaluation of anterior TWI in BA within Africa.

The prevalence of anterior TWI among healthy athletes varies with age, sex, sporting discipline and race.2 Since the 1950s it has been recognised that anterior TWI is more common in black than white populations.3 With a prevalence of up to 27.3% among BA,4 the ‘black athlete repolarisation variant’ (figure 1) is considered a normal ECG manifestation of exercise-induced cardiac remodelling, although its significance outside this ethnic cohort remains unclear.5 While used here for brevity, the ‘black athlete repolarisation variant’ assumes that the non-black pattern is the norm, and this racialised presumption warrants reconsideration in future guidelines.5 6 Recommendations for athlete ECG interpretation have largely been derived from studies in Europe and North America. Research conducted within Africa has been sparse, with …