Approach to a patient with T wave abnormality in ECG

A 45 years old lady presented with generalized weakness and palpitations. She is a diagnosed case of chronic renal failure with Diabetes mellitus and Hypertension. Her serum K+ level is 6.8 meq/L. She had the following ECG.
Case; A 54 years old gentleman complained of chest discomfort on exertion for the last 5 months. He is smoker for 10 years, diabetic for 5 years and hypertensive for 3 years. He had the following ECG.
Case: A 25 years old gentleman presented with chest pain and fever .He was normotensive, non-smoker and non-diabetic. His pulse 128b/min and BP-130/80 mm Hg. Troponin I was normal.
Case: A 58 years old gentleman complained of severe central chest pain with excessive sweating 5 days back. He is smoker for 7 years, diabetic for 5 years and hypertensive for 4 years. His BP-90/70 mm Hg. He had the following ECG.

1. Fundamentals of ECG
Approach to a patient presented with T wave
abnormalities in ECG
Dr. Md.ToufiqurRahman
MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FCCP,FAPSC, FAPSIC, FAHA,FACP
Professor & head of Cardiology
CMMC, Manikganj
Ex professor of cardiology,
NICVD, Dhaka

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T wave
Professor DrMdToufiqurRahman
•The T wave is the positive
deflection after each QRS
complex.
•It represents
ventricularrepolarisation.
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Fundamentals of ECG
Characteristics of the normal T
wave
Upright in all leads except
aVRand V1
Amplitude < 5mm in limb
leads, < 15mm in precordial
leads

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T wave
Professor DrMdToufiqurRahman
Fundamentals of ECG
A 45 years old lady presented with generalized weakness and palpitations. She is a
diagnosed case of chronic renal failure with Diabetes mellitus and Hypertension. Her
serum K+ level is 6.8 meq/L. She had the following ECG.
Figure: Tall, narrow, symmetrically peaked T-waves are
characteristically seen inhyperkalaemia.

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T wave
Professor DrMdToufiqurRahman
Fundamentals of ECG
Case; A 54 years old gentleman complained of chest discomfort on
exertion for the last 5 months. He is smoker for 10 years, diabetic for 5
years and hypertensive for 3 years. He had the following ECG.
Figure: T-waves inversions seen in V2-V6 suggesting anterior wall
ischemia.

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T wave
Professor DrMdToufiqurRahman
Fundamentals of ECG
Case: A 58 years old gentleman complained of severe central chest
pain with excessive sweating 5 days back. He is smoker for 7 years,
diabetic for 5 years and hypertensive for 4 years. His BP-90/70 mm Hg.
He had the following ECG.
Figure: T-waves inversions seen in V2-V6 suggesting anterior wall
ischemia.

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T wave
Professor DrMdToufiqurRahman
Fundamentals of ECG
T wave abnormalities
•Peaked T waves
•HyperacuteT waves
•Inverted T waves
•Biphasic T waves
•‘Camel Hump’ T waves
•Flattened T waves

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T wave
Professor DrMdToufiqurRahman
Fundamentals of ECG
Peaked T waves
Tall,narrow,symmetricallypeaked T-waves are
characteristicallyseeninhyperkalaemia

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T wave
Professor DrMdToufiqurRahman
Fundamentals of ECG
HyperacuteT waves
•Broad, asymmetrically peaked or
‘hyperacute’ T-waves are seen in the
early stages of ST-elevation MI (STEMI)
and often precede the appearance of
ST elevation and Q waves.
•They are also seen with Prinzmetal
angina.

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T wave
Professor DrMdToufiqurRahman
HyperacuteT waves
Prinzmetalangina.Loss of precordial T-wave balance
•LossofprecordialT-wavebalance
occurswhentheuprightTwaveis
largerthanthatinV6.Thisisatype
ofhyperacuteTwave.
•ThenormalTwaveinV1isinverted.
•AnuprightTwaveinV1is
consideredabnormal—especiallyif
itistall(TTV1),andespeciallyifitis
new(NTTV1).
Thisfindingindicatesahigh
likelihoodofcoronaryartery
disease,andwhennewimplies
acuteischemia.
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Fundamentals of ECG
Inverted T waves
Inverted T waves are seen in the following conditions:
Normal finding in children
Persistent juvenile T wave pattern
Myocardial ischaemiaand infarction
Bundle branch block
Ventricular hypertrophy (‘strain’ patterns)
Pulmonary embolism
Hypertrophic cardiomyopathy
Raised intracranial pressure
** T wave inversion in lead III is a normal variant. New T-wave inversion (compared
with prior ECGs) is always abnormal.
Pathological T wave inversion is usually symmetrical and deep (>3mm).

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T wave
Professor DrMdToufiqurRahman
Paediatric T waves
Inverted T-waves in the right precordial leads (V1-3) are a normal finding in
children, representing the dominance of right ventricular forces.
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Persistent Juvenile T-wave Pattern
•T-wave inversions in the right precordial leads may persist into
adulthood and are most commonly seen in young Afro-Caribbean
women.
•Persistent juvenile T-waves are asymmetric, shallow
(<3mm) and usually limited to leads V1-3.
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Myocardial Ischaemiaand Infarction
•T-waveinversionsduetomyocardialischaemiaor
infarctionoccurincontiguousleadsbasedonthe
anatomicallocationoftheareaof
ischaemia/infarction:Inferior=II,III,aVF;
Lateral=I,aVL,V5-6;Anterior=V2-6
DynamicT-waveinversionsareseenwithacute
myocardialischaemia.
FixedT-waveinversionsareseenfollowinginfarction,
usuallyinassociationwithpathologicalQwaves.
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Myocardial Ischaemiaand Infarction
Inferior T wave inversion due to acute ischaemia
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Myocardial Ischaemiaand Infarction
Inferior T wave inversion with Q waves –prior myocardial infarction
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Myocardial Ischaemiaand Infarction
T wave inversion in the lateral leads due to acute ischaemia
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Myocardial Ischaemiaand Infarction
Anterior T wave inversion with Q waves due to recent MI
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Bundle Branch Block (Left Bundle Branch Block)
Left bundle branch blockproduces T-wave inversion in the lateral leads I, aVLand V5-6.
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Bundle Branch Block (RightBundle Branch Block)
Right bundle branch blockproduces T-wave inversion in the right precordial leads V1-3.
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Left Ventricular Hypertrophy
Left ventricular hypertrophy (LVH)produces T-wave inversion in the
lateral leads I, aVL, V5-6 (left ventricular ‘strain’ pattern), with a similar
morphology to that seen in LBBB.
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Right Ventricular Hypertrophy
Right ventricular hypertrophyproduces T-wave inversion in the right
precordial leads V1-3 (right ventricular ‘strain’ pattern) and also the
inferior leads (II, III, aVF).
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Pulmonary Embolism
T wave inversion in the inferior and right precordial leads
Acute right heart strain (e.g. secondary to massivepulmonary
embolism) produces a similar pattern to RVH
•T-wave inversions in the right precordial (V1-3) and inferior (II, III, aVF) leads
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Pulmonary Embolism
Acute massive PE withS
IQ
IIIT
IIIRBBB TWI V1-3
S
IQ
IIIT
III
Pulmonary embolism may also produce T-wave inversion in lead III as
part of theS
IQ
IIIT
IIIpattern
S wave in lead I, Q wave in lead III, T-wave inversion in lead III
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Pulmonary Embolism
Acute massive PE withS
IQ
IIIT
IIIRBBB TWI V1-3
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Hypertrophic Cardiomyopathy (HCM)
Hypertrophic Cardiomyopathyis associated with deep T
wave inversions in all the precordial leads.
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Raised intracranial pressure (ICP)
Eventscausingasuddenriseinintracranialpressure(e.g.
subarachnoidhaemorrhage)producewidespreaddeepT-
waveinversionswithabizarremorphology.
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Biphasic T waves
There are two main causes ofbiphasic T waves:
Myocardial ischaemia; Hypokalaemia
The two waves go in opposite directions:
Biphasic T waves due toischaemia–T
waves goUPthenDOWN
Biphasic T waves due to Hypokalaemia
–T waves goDOWNthenUP
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
WellensSyndrome
Wellenssyndromeis a pattern of inverted or biphasic T waves in
V2-3 (in patients presenting with/following ischaemicsounding
chest pain) that is highly specific for critical stenosis of the left
anterior descending artery.
There aretwo patternsof T-wave abnormality in Wellenssyndrome:
Type A= Biphasic T waves with the initial deflection
positive and the terminal deflection negative (25% of
cases)
Type B= T-waves are deeply and symmetrically
inverted (75% of cases)
The T waves evolve over time from a Type A to a Type B
pattern
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
WellensSyndrome (WellensType A)
Biphasic T waves with the initial deflection positive and the
terminal deflection negative
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
WellensSyndrome (WellensType B)
T-waves are deeply and symmetrically inverted
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Camel hump’ T waves
•‘Camel hump’ T waves is a term used by AmalMattuto describe T-waves that have a
double peak. There are two causes for camel hump T waves:
Prominent U wavesfused to the end of the T wave, as seen in severe
hypokalaemia
Hidden P wavesembedded in the T wave, as seen in sinus tachycardia and various
types of heart block
Prominent U waves due to
severe hypokalaemia
Hidden P waves in sinus tachycardia
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Camel hump’ T waves
Hidden P waves in marked 1st
degree heart block
Hidden P waves in 2nd degree
heart block with 2:1 conduction
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Flattened T waves
Dynamic T wave flattening
due to anterior ischaemia
Flattened T waves are a non-specific finding, but may represent ischaemia(if
dynamic or in contiguous leads) or electrolyte abnormality, e.g.hypokalaemia(if
generalised).
T waves return to normal as
ischaemiaresolves
Fundamentals of ECG

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T wave
Professor DrMdToufiqurRahman
Flattened T waves
Hypokalaemia
GeneralisedT-wave flattening in hypokalaemiaassociated with prominent U waves
in the anterior leads (V2 and V3)
Fundamentals of ECG