ECG Rounds The Flippancy of T Waves

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ECG RoundsThe Flippancy of T Waves

• March 6, 2003
• Moritz Haager
• PGY-2

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One only needs to take a closer look to
appreciate that..

• "You need to tell your loved ones, the little
  ones in particular, that when they hear the
  President talking about al Qaeda, Iraq and other
  places, I do so because I long for peace."
• George W. Bush - Louisville, Kentucky, Sept. 5,
  2002

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.perspective is everything
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Case 1

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

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Case 1
A PE w/ S1Q3T3 inverted T waves in inferior
and antero-lateral leads
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Case 2

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

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Case 2
A hyperacute Ts mild STE in V2-V4
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Case 2
A biphasic T waves in V1-V3 pathognomonic for
Wellens Syndrome
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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

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Diagnostic Criteria for Wellens Syndrome

• History of anginal pain
• Normal or minimally elevated cardiac enzymes
• Isoelectric or minimal (lt1mm) 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

Rhinehardt et al. Am J Emerg Med 2002 20 638-643
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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
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Case 3
A deep T wave inversions in V2-V6 consistent
with Wellens Syndrome
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Case 4
A Biphasic T waves of Wellens Syndrome
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• "I want to send the signal to our enemy that you
  have aroused a compassionate and decent and
  mighty nation, and we're going to hunt you down.
  George W. Bush - Kentucky, Sept. 5, 2002

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Case 5

• 47 yo M c/o chest pain
• Vitals 55, 112/72, 28, 98 R/A
• Diaphoretic
• Normal exam otherwise

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Case 5
A T wave inversion in V1-V4 consistent with
acute ischemia
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Acute Coronary TWI

• Symmetrical
• Narrow
• Small amplitude

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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

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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

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Case 6
A ischemic T wave inversions, in this case
secondary to NSTEMI
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Wellens vs. ACS
Ischemic T Wave
Wellens T Wave
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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.

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Case 7
A diffuse T wave inversion due to CNS hemorrhage
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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 (lt3mm)
• Most pronounced in mid lateral precordial leads
• Prominent U waves (up or down)
• QT prolongation (by up to 60 of normal)

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CNS T Wave Inversions

• Deeply inverted
• Widely splayed
• Asymmetric
• ST elevation

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Case 8

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

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Case 8
A scooped-out ST segments and T wave inversion
due to digoxin
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Digitalis Effect

• Flat or inverted
• T waves
• ST depression w/
• scooped-out
• appearance
• U waves
• Prolonged PR
• Prolonged QTc

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Case 9

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

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

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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
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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