A 61-Year-Old Woman with a 2-Day History of Chest Pain

ECG Differential diagnosis:

• ST-Elevation myocardial infarction (STEMI)
• Acute right heart strain
• Left ventricular hypertrophy (LVH)
• Ischemic T-wave inversions/Myocardial ischemia
• Hypertrophic cardiomyopathy

Diagnosis

 This patient was diagnosed with ischemic T-wave inversions/myocardial ischemia. The ECG reveals a sinus rhythm at a rate of 72 beats per minute. There is a normal axis and normal intervals. There are symmetric T-wave inversions in the high lateral leads (1, aVL), as well as a biphasic t-wave in V2. There are no ST elevations or depressions.

T-wave inversions in leads aVR and V1 are normal characteristics on the ECG, and an isolated T-wave inversion in lead III is a normal variant (“a flipped T is free in III”). Inverted t-waves can also be a normal finding in pediatric ECGs. New T-wave inversions when compared to old ECGs are always abnormal.

There are many causes of T-wave inversions, and ECG interpretation should occur within the clinical context of the patient’s presentation; our patient is presenting with symptoms consistent with acute coronary syndrome, and the finding of symmetric T-wave inversions in contiguous anatomical leads (lateral leads) is consistent with myocardial ischemia. Dynamic T-wave inversions on serial ECGs are typically seen with acute ischemia, whereas fixed T-wave inversions are seen after infarction and are often associated with pathologic Q-waves.¹

Other causes of T-wave inversions include persistent juvenile T-wave pattern, normal repolarization changes after a bundle branch block, left ventricular hypertrophy, acute right heart strain as often seen in pulmonary embolism, hypertrophic cardiomyopathy, takotsubo cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy,² and cardiac memory,³ as well as elevated intracranial pressure.

Distinguishing between ischemic T-wave inversions and T-wave inversions of ventricular hypertrophy is important for accurate diagnosis. Ischemic T-waves are found in contiguous leads and tend to be symmetric and deep, whereas T-wave inversions secondary to the “strain” of left ventricular hypertrophy are found in the lateral and high lateral leads (I, aVL, V5 and V6) and are asymmetric (Figure 3).⁴ ECGs consistent with the “strain” of left ventricular hypertrophy should also meet voltage criteria for the diagnosis.

Learnings/What to Look for

• The differential for T-wave inversions is broad and includes:
  • Juvenile T-wave pattern
  • Normal repolarization changes after a bundle branch block
  • Left ventricular hypertrophy
  • Acute right heart strain as often seen in pulmonary embolism
  • Hypertrophic cardiomyopathy
  • Takotsubo cardiomyopathy
  • Arrhythmogenic right ventricular cardiomyopathy
  • Cardiac memory
  • Elevated intracranial pressure
  • Normal in pediatric patients
• The correct interpretation of T-wave inversions relies on the clinical presentation
• Dynamic T-wave inversions on serial ECGs are consistent with acute ischemia in the setting of acute coronary syndrome.
• Differentiating between ischemic T-wave inversions and the strain pattern of ventricular hypertrophy is based on the morphology of the T-wave and voltage criteria of the QRS

Pearls for Urgent Care Management

• Utilize the clinical history in tandem with the ECG to identify the cause of T-wave inversion
• Serial ECGs, as well as comparison to prior ECGs, can help guide decision making
• In the setting of acute coronary syndrome, identification of acute ischemic T-wave inversions on ECG should prompt the provider to transfer the patient to a coronary intervention-capable facility

References

1. Wagner GS, Strauss DG. Marriott’s Practical Electrocardiography. 12th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.
2. Haugaa KH, Haland TF, Leren IS, et al. Arrhythmogenic right ventricular cardiomyopathy, clinical manifestations, and diagnosis. Europace. 2016;18(7):965–972.
3. Polito SC, Giordano JA, Cooper BL. Cardiac memory-induced T-wave inversions. Clin Pract Cases Emerg Med. 2020 Apr 14;4(2):181-184.
4. Wagner GS, Macfarlane P, Wellens H, et al. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. Part V: Electrocardiogram Changes Associated with Cardiac Chamber Hypertrophy. Circulation. 2009;53(11):1003-1011.

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