1. Elias Hanna, MD LSU Cardiology
Global T inversion
Elias Hanna, MD
LSU Cardiology

2. Patient presents with acute pulmonary edema and mildly increased troponin 0.12

3. Normal sinus rhythm
Global T wave inversion (>10 mm) in most leads with prolonged QTc (~560 msec)

4. What is Global (Diffuse) T-wave inversion?
T wave is inverted in most of the standard leads except aVR, which shows a reciprocal upright T wave.
The QT interval is often prolonged, and T-wave inversion is often symmetric and “giant” (> 10 mm, i.e, > 2 big boxes).
This is different from Wellens T waves, wherein the T abnormality is limited to the anterior leads (esp V2-V4) and ST segment is slightly upsloping

5. Causes of Global T-wave inversion
1-Myocardial ischemia
2-Intracranial hemorrhage or any intracranial process
3-Hypertrophic cardiomyopathy
4-High catecholamine states: cocaine use, pheochromocytoma, Takotsubo (stress-induced) cardiomyopathy
5-Other: peri/myocarditis, high-grade AV block, PE
Most
common

6. Coronary angiography shows non-obstructive CAD
Echocardiogram and Lvgram show apical dyskinesis with preserved basal contractility and EF ~20%
Acute non-ischemic HF
Low EF with apical dyskinesis
Mild troponin increase
Deep T inversion
No CAD
Takotsubo
Cardiomyopathy

7. Takotsubo cardiomyopathy
OR:
Stress-mediated cardiomyopathy
Apical ballooning syndrome
Broken heart syndrome

8. 95% of Takotsubo cases are seen in Females>55 yo
95% of Takotsubo cases are seen in Females>55 yo. It is very uncommon in men or <50 yo
Usually presents as CP with mild increase in troponin and ST-elevation in the anterior leads, mimicking STEMI
ST elevation is followed by deep T inversion with prolonged QT. If diagnosed at this stage, Takotsubo mimicks NSTEMI
HF presentation is less common (17%)

9. Functional MR is seen in 20% of cases, related to tethering of the mitral valve
Very good prognosis with a low risk of early death or compplications (VT, stroke, cardiogenic shock)
~1% risk of death
LV dysfunction always resolve within 2 months, usually 1-2 weeks
Recurrence 11% over 4 yrs