Objective <p>This study aims to explore the prevalence of non-specific ST-segment and T-wave abnormalities (NSSTTA) in patients with SLE and evaluate the predictive value of NSSTTA indices for major adverse cardiovascular and cerebrovascular events (MACCE) in SLE patients.</p> Methods <p>This study retrospectively enrolled 395 hospitalized SLE patients and 420 controls from health examinations, during the period from January 1, 2014, to December 31, 2024. After propensity score matching (PSM), ECG indices were compared between the SLE group and the control group. Multivariable Cox regression analysis was used to assess the association between NSSTTA and MACCE.</p> Results <p>Compared with the control cohort, patients with SLE demonstrated significantly higher prevalence rates of NSSTTA (16.7% vs. 6.4%, <i>p</i> &lt; 0.001). Multivariable Cox proportional hazards analysis further identified advancing age (HR = 1.027, 95% CI: 1.002–1.053, <i>p</i> = 0.033), comorbid interstitial lung disease (ILD, HR = 3.024, 95% CI: 1.477–6.193, <i>p</i> = 0.002), non-specific ST-T abnormalities (HR = 3.082, 95% CI: 1.209–7.853, <i>p</i> = 0.018), and elevated serum uric acid (HR = 1.004, 95% CI: 1.001–1.007, <i>p</i> = 0.021) as independent predictors for MACCE in the SLE cohort.</p> Conclusions <p>NSSTTA are independently associated with adverse outcomes and facilitate cardiovascular risk stratification in patients with SLE.</p>