The Inverted T Wave

Differential Diagnosis

Dr. Malala Rajapaksha.

Cardiology UnitGenaral HospitalMatara

The T wave the positive deflection after each QRS complex.

It represents ventricular repolarization.

T wave abnormalities

• Hyper acute T waves• Inverted T waves• Biphasic T waves• ‘Camel Hump’ T waves• Flattened T waves

normal T wave

• The normal T wave has been described to have a gradual upstroke with a more rapid downstroke in the terminal portion. This relative asymmetry may vary because many females and elderly individuals, without identifiable cardiac disease, may have symmetric T waves.

normal T wave

normal T wave

• The T wave is normally upright in leads I, II, and V3 to V6

• inverted in lead aVR• and variable in leads III, aVL, aVF, and V1 V2

• In general, an inverted T wave in a single lead in one anatomic segment (ie, inferior, lateral, or anterior) is unlikely to represent acute pathology; for instance, a single inverted T wave in either lead III or aVF can be a normal variant.

The Inverted T Wave

• The natural history of the inverted T wave is variable, ranging from a normal life without pathologic issues to sudden death related to cardiac or respiratory syndromes.

• A variety of clinical syndromes can cause T-wave inversions, ranging from life-threatening events, such as acute coronary ischemia, pulmonary embolism, and CNS injury, to entirely benign conditions, such as normal variant T- wave inversions and the persistent juvenile T-wave inversion.

Causes for Inverted T Wave • Coronary artery disease (acute coronary syndrome, chronic ischemic syndromes)• Pulmonary causes• Inflammatory causes• Neurogenic causes• Bundle-branch block and ventricular paced (implanted pacemaker) patterns• Left ventricular hypertrophy by voltage• Right Ventricular Hypertrophy• Hypertrophic Cardiomyopathy (HOCM)• Ventricular pre-excitation syndrome• Normal variant (or benign) causes

Coronary artery disease (acute coronary syndrome, chronic ischemic syndromes)

T-wave inversions associated with coronary artery disease may result from 1. myocardial ischemia (unstable angina)2. non–ST-segment elevation acute myocardial infarction

(NSTEMI-MI)3. previous MI

ECG Changes in Coronary artery disease

Non Specific ECG

UNSTABLE ANGINA

ST Depression or Dynamic T wave

inversion

NSTEMI

ST Elevation or new LBBB

STEMI

T-wave inversions associated with coronary artery disease

• In general, inverted T waves related to acute coronary syndrome are symmetric in shape.

• this symmetry means that the down sloping limb is a mirror image of the upsloping limb.

T-wave inversions associated with coronary artery disease

• An important subgroup of patients with pre-infarction angina (unstable angina) can present with significantly abnormal T-wave inversions—either symmetric, deeply inverted T waves or biphasic T waves in the precordial leads (V1, V2, and V3 in particular).

• In patients with this history and these ECG findings, Wellen syndrome is diagnosed, which is frequently associated with proximal left anterior descending coronary artery critical stenosis;

• the natural history of Wellen syndrome is anterior wall ST-segment elevation myocardial infarction.

T-wave inversions associated with coronary artery disease

• previous MI

Pulmonary causes

pulmonary embolism• Patients with pulmonary embolism (PE) may also display T-wave

abnormalities, including T-wave inversions . • The T-wave findings in these patients are typically shallow inversions in the

inferior leads. • Deeper T-wave inversion attributed to acute right ventricular strain and

occasionally seen in patients with massive PE are generally observed in the right to mid-precordial leads V1 to V4

• SI QIII TIII  pattern – deep S wave in lead I, Q wave in III, inverted T wave in III. This “classic” finding is neither sensitive nor specific for pulmonary embolism; found in only 20% of patients with PE.

pulmonary embolism• RBBB• Extreme right axis

deviation (+180 degrees)• S1 Q3 T3• T-wave inversions in V1-4

and lead III• Clockwise rotation with

persistent S wave in V6•  

Inflammatory causes• Acute myocarditis and acute myopericarditis can present

with a range of ECG abnormalities, including ST-segment elevation and T-wave inversion.

• T-wave inversion is not seen in all such cases of myocardial inflammatory disorders.

• When it is seen in these patients, T-wave inversion usually indicates a resolving process

Myocarditis

• ECG Changes can be variable and includeSinus tachycardiaQRS, QT ProlongationDiffuse T wave inversionVentricular arrhythmiasAV Conduction defects

Pericarditis

Diffuse ST Elevation

Normalization of ST and PR

SegmentDiffuse T wave

inversion

Normalization of ECG or

Persistence of T inversion

pericarditis

• Initial ECG shows widespread 1 mm concave ST elevations in leads V3–6, II and aVF.

pericarditis• Second ECG shows

widespread convex ST elevations of up to 9 mm, and T-wave inversions in leads V2–6, I, II, aVL and aVF, as well as reciprocal ST depressions in leads aVR and V1.

pericarditis• Subsequent

ECG shows normalization of ST segments and widespread T-wave inversions in leads V3–6.

ECG –Acute MI vs pericarditisAMI Pericarditis

Morphology Convex ST Elevation Concave ST ElevationDistribution Limited to anatomical

grouping of leadsGeneralized

Reciprocal changes

Common Not seen

Hyper acute T wave

May occur Do Not

Q waves May occur Do Not

PR Segment depression

Absent Frequently seen

Neurogenic causes• There are a number of neurogenic causes of primary T-

wave inversions.• For example, 1. CNS hemorrhage2. ischemic infarction 3.  Prolonged status epilepticus

CNS hemorrhage or ischemic infarction

• T waves in patients who have sustained a CNS hemorrhage or ischemic infarction are inverted with a distinctly deep, widely splayed appearance with an outward bulge of the descending limb that results in a striking asymmetry

Bundle-branch block• Bundle-branch block produce a number of abnormalities

of the ST segment and T wave.• In general, leads with large positive QRS complexes will

demonstrate T-wave inversions. • In left bundle-branch block pattern, inverted T waves are

seen in leads I, aVL, V5, and V6. In right bundle-branch block pattern, T waves are inverted in leads V1 and V2. 

left bundle-branch block

right bundle-branch block

ventricular paced (implanted pacemaker) patterns

•  In patients with implanted right ventricular pacemakers, inverted T waves are most often seen in leads I and aVL.

• The T waves are inverted in an asymmetric fashion with a gradual initial downslope and an abrupt return to the baseline.

ventricular paced (implanted pacemaker) patterns

Left ventricular hypertrophy• If the summation of the negative component of the QRS complex in lead

V1 and the positive component of the QRS complex in lead V6. is greater than 35 mm the LVH is diagnosed.

• In patients with LVH, ST-segment/T-wave changes are encountered in approximately 70% of cases, including ST-segment deviations and abnormal T waves.

• Of these findings, the T wave can be inverted and is most often seen in leads with large positive QRS complexes, such as leads I, aVL, V5, and V6

•  These inverted T waves have a gradual down sloping limb with a rapid return to the baseline. These abnormalities are related to the LVH pattern and are not suggestive of ACS.

Left ventricular hypertrophy

Right Ventricular Hypertrophy

• Right Ventricular Hypertrophy produces T-wave inversion in the right precordial leads V1-3 (right ventricular ‘strain’ pattern) and also the inferior leads (II, III, aVF).

Hypertrophic Cardiomyopathy (HOCM)

• HOCM is associated with deep T wave inversions in all the precordial leads.

Wolff-Parkinson-White syndrome• Although the ECG morphology varies widely, the classic ECG features

are as follows:• A shortened PR interval (typically <120 ms in a teenager or adult)• A slurring and slow rise of the initial upstroke of the QRS complex

(delta wave)• A widened QRS complex (total duration >0.12 seconds)• ST segment–T wave (repolarization) changes, generally directed

opposite the major delta wave and QRS complex, reflecting altered depolarization

Wolff-Parkinson-White syndrome

digitalis effect

These include• T-wave inversions• flattened T waves • an increased U wave• a prolonged PR interval• ST-segment depression with a distinct “scooped” appearance• short QT interval

digitalis effect

Normal variant (or benign) causes

•  persistent juvenile T-wave pattern• Athletic heart•  Isolated T-wave inversion in a single lead is not abnormal• Inverted T-waves in the right precordial leads (V1-3) are a

normal finding in children

Application

• Awareness of the differential diagnosis of T wave inversion will help to discern different entities and will prevent some patients from undergoing unnecessary invasive investigations and procedures.

Thank you