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Introduction Anterior T-wave inversion (ATWI) confined to lead V 1-V4 preceded by convex ST elevation has been considered as a normal finding in athletes with black ethnicity. ATWI in non-Black athletes may indicate cardiomyopathy associated with sudden cardiac death (SCD). More recent data sets however, have challenged this interpretation and deemed ATWI in V1-V4 as a normal variant among both non-Black athletes and Black athletes. We aimed to assess the prevalence and significance of ATWI in professional black and non-black football players from the UK.Methods In this observational cross-sectional study, football players underwent preparticipation screening as part of the English Football Association (FA) programme in 2017-2024. Each player underwent a health questionnaire, 12-lead ECG and transthoracic echocardiogram. Clinical outcomes were assessed by an expert sports cardiologist. Each player was categorised into black and non-black players according to their ethnicity. ATWI was defined as TWI confined to lead V 1 to V3 or V4.Results 10,995 football players were studied, comprising 9,009 (82.2%) males and 1,946 (17.8%) females. 2,372 (21.7%) players were black ethnicity and 8,583 (78.3%) were non-black. The non-black group were predominantly white (98%) with the remainder being Asian (2%). The mean age of black players was 18.3±3.8 years vs 19.2±4.7 years in non-black players (p<0.001).ATWI was observed in 205 (10.8%) black players vs 115 (1.3%) non-black players (p<0.001). ATWI was more common in males compared to females among black players (201 [11.0%] vs 4 [4.3%]; p=0.04). Among non-black players, ATWI was less common in males (81 [1.2%] vs 34 [1.9%]; p=0.04). ST-segment elevation preceding ATWI was twice as common in Black players compared to non-Black players (246 [96.4%] vs 55 [47.8%]; p<0.001).No black players with ATWI had major cardiac pathology associated with SCD, whereas one (0.9%) non-black player was diagnosed with arrhythmogenic cardiomyopathy (p=0.34). Minor cardiac conditions were identified in four (1.6%) black players and two (1.7%) non-black players (p=1.00). Among the four black players with minor cardiac pathology, two had aortic root dilatation, one had a patent ductus arteriosus and one had moderate valvular regurgitation. Among the two non-black players with minor cardiac conditions, one had a patent ductus arteriosus and one had moderate valvular regurgitation. Both black and non-black players with minor cardiac pathology did not show other ECG changes apart from ATWI.Conclusion ATWI was observed nearly nine times more frequently in black football players than in non-black players. ATWI in non-black athletes should prompt further investigation because of the rarity and risk of underlying cardiomyopathy.Acknowledgement We thank the English Football Association Cardiac Advisory Group for their input.