BACKGROUND: The presence of ventricular repolarization abnormalities (VRA) in young asymptomatic athletes is rare and may represent initial expression of underlying ongoing cardiomyopathy, increasing risk of sudden cardiac death. This study aims to evaluate the long-term prognosis of VRAs in this specific population. METHODS: A cohort of 28 young asymptomatic Caucasian male athletes with VRA on 12‑leads electrocardiogram (ECG), initially underwent transthoracic echocardiography (TTE) and treadmill test between1990-2000 which excluded cardiac diseases. The same tests where repeated between 2021 and 2023, after a 25-year follow-up period. Cardiac magnetic resonance (CMR) was also prescribed in 6 selected cases. VRA were described as T-wave inversion (TWI) and it was categorized into three different patterns based on the distribution of TWI on ECG. RESULTS: After 25-years follow-up, all subjects remained alive without major cardiac adverse events. Among them, 11 % developed significant structural changes suggestive of underlying cardiomyopathy, including 3 (11 %) cases of hypertrophic cardiomyopathy. All pathological cases exhibited VRA Type 2 pattern (isolated TWI in left precordial leads) or Type 3 patterns (diffuse TWI in precordial leads ± some or all limb leads). However, the most common VRA pattern observed at the beginning of the study was characterized by isolated right precordial leads TWI (type 1) associated with ST-segment elevation, which was characterized by an uneventful follow-up. CONCLUSION: Marked abnormal repolarization in young asymptomatic athletes with Type 1 pattern, in the absence of structural abnormalities, is highly associated with benign outcomes during long-term follow-up. The presence of diffuse or left precordial TWI (VRA Type 2 or 3) should be carefully evaluated, as it is related with cardiomyopathy development. SUMMARY: A follow-up of 28 young Caucasian male athletes initially identified with VRA on routine ECG, without evidence of structural heart disease. The study delineates the incidence of cardiomyopathy development and assesses cardiovascular outcomes over an extended period of 25 years follow-up.