APCU25MPC2 When abnormal is not abnormal: a case report of t-wave inversion in female para-cyclist with cerebral palsy

Introduction Athletes with neurological impairments such as cerebral palsy (CP) present unique challenges in cardiovascular screening. Usually, T-wave inversion in leads V1–V4 on an athlete’s electrocardiography (ECG) is classified as abnormal and always prompt further evaluation. However, in athlete with CP, differentiating between training-induced ECG remodeling from true pathology is confounded by the sex-specific reference range, the cardiac adaptations of chronic endurance training, and possible autonomic dysfunction inherent to CP.Case Presentation A 30-years-old, female paracyclist was referred to the Sports Medicine Clinic, Universiti Malaya Medical Centre (UMMC) for evaluation of atypical chest discomfort and T-wave inversion in anterior leads (V1–V4). Comprehensive cardiovascular assessment was performed including detailed history, physical examination, Cardiopulmonary Exercise Testing (CPET), Stress Echocardiography, and Cardiac Magnetic Resonance Imaging (MRI) with perfusion.Results Family history was notable for early-onset heart disease in a sibling. Clinical examination revealed a split-second heart sound (S2), with no signs of heart failure. ECG showed T-wave inversion of 2-3mm at V1-V4. CPET demonstrated a reduced oxygen pulse (O 2/HR) of 9.6mL/beat, slightly below normative values for females. Cardiac MRI with perfusion showed no structural defects but revealed a mildly reduced left ventricular ejection fraction (LVEF) of 43%, and right ventricular ejection fraction of 41%. Subsequently, the athlete was referred to cardiologist and decided for dobutamine stress echocardiography, which eventually showed good augmentation of all myocardial regions and a 16.4% increase in EF from baseline.Discussion This case highlights the importance of a multidisciplinary approach to cardiovascular screening in athletes, especially with neurological impairment. The combination of abnormal ECG, low oxygen pulse, and borderline reduced LVEF (45-50%) warrants cautious interpretation in competitive athletes. Overreliance on a single metric may lead to diagnostic misclassification.Conclusion Although comprehensive evaluation excluded cardiomyopathy and myocardial ischemia, this athlete’s overall profile remains consistent with a low-risk classification for cardiovascular disease. This case highlights the need for expanded ECG norms for female athletes especially with neurological impairments. Yet, ECG remains reasonable in screening cardiology diseases, and further advanced diagnostic investigations still need multidisciplinary inputs. Nevertheless, accurate diagnosis will not only safeguards athlete health but also prevents unnecessary restrictions in competitive sport.