1. ECG Rounds The Flippancy of T Waves
March 6, 2003
Moritz Haager
PGY-2

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George W. Bush - Louisville, Kentucky, Sept. 5, 2002

3. …….perspective is everything

4. Case 1 44 yo F c/o SOB. PMHx HTN. Vitals 118, 155/97, 34, 97% 2 lpm
Alert, oriented. Normal exam.
Normal CXR

5. Case 1
Pe s1q3t3 + inverted T waves
A: PE w/ S1Q3T3 + inverted T waves in inferior and antero-lateral leads

6. Case 2 59 yo F w/ chest pain x 4 hrs PMHx HTN Vitals normal
Diaphoretic
Pain free after given NTG.

7. Case 2 A: hyperacute T’s & mild STE in V2-V4
Case 5 hyperacute T’s, mild STE, also straightening of proximal segment of T waves
A: hyperacute T’s & mild STE in V2-V4

8. Case 2
A: biphasic T waves in V1-V3 pathognomonic for Wellens’ Syndrome

9. Wellens’ Syndrome
Specific ECG pattern highly specific for a proximal LAD occlusion
Seen in 14-18% of pts with unstable angina
Seen in pain-free state; ECG changes may normalize or evolve into STE during attack
Progress to extensive anterior MI if untreated
Do NOT stress test these patients; they all need urgent angiography

10. Diagnostic Criteria for Wellens’ Syndrome
History of anginal pain
Normal or minimally elevated cardiac enzymes
Isoelectric or minimal (<1mm) ST elevation
No precordial Q waves
Characteristic ECG pattern while PAIN-FREE consisting of:
Symmetrical deeply inverted T waves in V2 & V3; & occassionally in any of V1, V4, V5, V6 Or
Biphasic T wave in leads V2 and V3
2/3 of pts will have changes in V1 and 75% will have it in V4. Less commonly V5 and 6 can be involoved
Over 90% of these patients will exhibit these changes by 24 hrs afer admission
Rhinehardt et al. Am J Emerg Med 2002; 20:

11. Wellens’ T Wave Inversion Patterns
A – C show the more common (~75%) deep inversion pattern
E – F show the less common (~25%) biphasic
pattern
Note depth &
symmetry of
deflection &
acute angle b/w
baseline &T wave
nearing 90o

12. Case 3 A: deep T wave inversions in V2-V6 consistent with
Wellens’ Syndrome

13. Case 4 A: Biphasic T waves of Wellens’ Syndrome
Fig 2 Manifestation of Wellens
A: Biphasic T waves of Wellens’ Syndrome

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15. Case 5 47 yo M c/o chest pain Vitals: 55, 112/72, 28, 98% R/A
Diaphoretic
Normal exam otherwise

16. Case 5 A: T wave inversion in V1-V4 consistent with acute ischemia

17. Acute Coronary TWI Symmetrical Narrow Small amplitude
Classically narrow & symmetric
Symmetrical
Narrow
Small amplitude

18. Wellens’ vs. Ischemia A – B are examples of the two Wellens’ variants
C – D are examples of acute ischemic T wave inversions not characteristic of Wellens’.
Primary differentiating feature is depth of T wave inversion

19. Case 6 50 yo M c/o chest pain PMHx DM, HTN.
Vitals 90, 105/65, 30, 97% RA
Diaphoretic. Anxious. Exam otherwise normal.
Ongoing pain despite NTG

20. Case 6 A: ischemic T wave inversions, in this case secondary to NSTEMI
Case 3 AMI
Pt does not respond to nitrates and O2. Tn comes back elevated
A: ischemic T wave inversions, in this case secondary to NSTEMI

21. Wellens’ vs. ACS
Ischemic T Wave
Wellens’ T Wave

22. Case 7 61 yo F. Unresponsive. Last seen 6 hrs prior. PMHx HTN, DM
120, 110/60, 24, 98% RA
GCS 9. No focal findings.

23. Case 7 A: diffuse T wave inversion due to CNS hemorrhage
Left temperoparietal bleed, T wave inversion in inferior, and anterolateral leads w/ accompanying ST elevation in the precordial leads
A: diffuse T wave inversion due to CNS hemorrhage

24. CNS ECG Manifestations
Various intracranial events – SAH most common
Seen in ~60% of SAH
Dysfunction of autonomic control +/- myocardial damage
ECG features:
Diffuse deep T wave inversions
Can be up to 15 mm deep
Asymmetric w/ typical outward bulge in ascending portion
Minor STE (<3mm)
Most pronounced in mid – lateral precordial leads
Prominent U waves (up or down)
QT prolongation (by up to 60% of normal)

25. CNS T Wave Inversions Deeply inverted Widely splayed Asymmetric
ST elevation

26. Case 8 64 yo M c/o chest pain x 2 hrs PMHx CHF Normal vitals
Tender chest wall.

27. Case 8 A: scooped-out ST segments and T wave inversion due to digoxin
Case 9 dig effect
A: scooped-out ST segments and T wave inversion due to digoxin

28. Digitalis Effect Flat or inverted T waves ST depression w/ scooped-out
appearance
U waves
Prolonged PR
Prolonged QTc

29. Case 9
34 yo male c/o chest pain
No PMHx.
Normal vitals.
Pain free now

30. Case 9 A: T wave inversions due to persistent juvenile T-wave pattern

31. Differential for T Wave Inversion
Myocardium
Ischemia / infarction
Ventricular strain
Myocarditis PE
Digitalis effect
BBB
Idiopathic global TWI
CNS events
SAH / ICH
CVA
Tumor
Arrythmias
Posttachycardia pattern
WPW
Ventricular pacing
Ventricular ectopy
Normal Variants
Benign early repolarization
Juvenile T-wave pattern

32. FINAL
EXAM
A: A Wellens’, B Ischemia, C NSTEMI, D PE, E BBB, F LVH, G Dig effect, H persistent
Juvenile T waves, I SAH

33. Summary Lots of things cause T wave inversion
Diagnosis is guided by your history + physical
Probably the single most important diagnosis to know is Wellens’ syndrome
Wellens’ indicates significant LAD stenosis and mandates angiography

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"We need an energy bill that encourages consumption." - Trenton, N.J., Sept. 23, 2002
"We need an energy bill that
encourages consumption.“
- Trenton, N.J., Sept. 23, 2002