27-Year-Old with History of Asthma

Differential Diagnosis

• Myocardial infarction
• Anterior ischemia
• Left bundle branch block
• Arrhythmogenic right ventricular cardiomyopathy (AVRC)
• Persistent juvenile T-wave pattern (PJTWP)

Diagnosis

The diagnosis in this case is persistent juvenile T-wave pattern. TheECG shows a normal sinus rhythm with a rate of 90 beats per minute. There are inverted T-waves in leads V1-V3 with no Q waves or ST-elevations.

Discussion

Inverted T-waves in V1-3 are a normal finding in children—the result of right ventricular dominance. While in utero, the neonate’s right ventricle strengthens as it pushes against the pulmonary circulation. After birth, this right ventricular prominence decreases and the juvenile ECG pattern of T-wave inversion in V1-3 gradually evolves into an adult pattern (inversion only in V1) by about age 10.¹

In some patients, inversions in V1-3 carry on into adulthood. This persistent juvenile T wave pattern is most commonly found in African American women under the age of 30. The pattern does not portend structural changes; it is purely electrical and physiologically normal. While there are no specific diagnostic criteria, the hallmark ECG finding is asymmetric, shallow (<3 mm), inverted T-waves in leads V1-V3 (Figure 2).²

While ischemia or infarction can cause T-wave inversions, ischemic T wave inversions are generally symmetric and often accompanied by dynamic changes on subsequent ECGs. AVRC, a cause of sudden cardiac death in young people, may also have inverted T-waves in V1-V3, however the most specific finding is epsilon waves. Consider ARVC in patients with unexplained syncope or ventricular dysrhythmias. The QRS is narrow, excluding the possibility of bundle branch blocks.

Persistent T-wave pattern is a benign condition that requires no additional workup or treatment. While there are not strict diagnostic criteria for this pattern, it remains primarily a diagnosis of exclusion.

What to Look For

• Persistent juvenile T-waves are asymmetric, shallow (<3 mm), inverted T-waves in leads V1-3
• PJTWP is primarily seen in young African American females under the age of 30
• PJTWP should only be diagnosed after considering more dangerous causes of inverted T-waves including ischemia, pulmonary embolism, and ARVC

Initial Management, Considerations for Transfer

• The PJTWP is benign and does not require additional workup or transfer

References

1. Dickinson DF. The normal ECG in childhood and adolescence. Heart. 2005 Dec;91(12):1626-30.
2. Marcus FI.  Prevalence of T-Wave Inversion Beyond V1 in Young Normal Individuals and Usefulness for the Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia.  Am J Cardiol. 2005;95:1070-1071.

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