Approach to a patient with T wave abnormality in ECG

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

drtoufiq1971@gmail.com
T wave
Professor Dr Md Toufiqur Rahman
• The T wave is the positive
deflection after each QRS
complex.
• It represents
ventricular repolarisation.
Fundamentals of ECG

T wave
Fundamentals of ECG

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

T wave
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 in hyperkalaemia.

T wave
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.

T wave
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.

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

T wave
Fundamentals of ECG
Peaked T waves
Tall, narrow, symmetrically peaked T-waves are
characteristically seen in hyperkalaemia

T wave
Fundamentals of ECG
Hyperacute T 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.

T wave
Hyperacute T waves
Prinzmetal angina. Loss of precordial T-wave balance
• Loss of precordial T-wave balance
occurs when the upright T wave is
larger than that in V6. This is a type
of hyperacute T wave.
• The normal T wave in V1 is inverted.
• An upright T wave in V1 is
considered abnormal — especially if
it is tall (TTV1), and especially if it is
new (NTTV1).
 This finding indicates a high
likelihood of coronary artery
disease, and when new implies
acute ischemia.
Fundamentals of ECG

T wave
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 ischaemia and 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).

T wave
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

T wave
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

T wave
Myocardial Ischaemia and Infarction
• T-wave inversions due to myocardial ischaemia or
infarction occur in contiguous leads based on the
anatomical location of the area of
ischaemia/infarction: Inferior = II, III, aVF;
Lateral = I, aVL, V5-6; Anterior = V2-6
Dynamic T-wave inversions are seen with acute
myocardial ischaemia.
Fixed T-wave inversions are seen following infarction,
usually in association with pathological Q waves.
Fundamentals of ECG

T wave
Inferior T wave inversion due to acute ischaemia
Fundamentals of ECG

T wave
Inferior T wave inversion with Q waves – prior myocardial infarction
Fundamentals of ECG

T wave
T wave inversion in the lateral leads due to acute ischaemia
Fundamentals of ECG

T wave
Anterior T wave inversion with Q waves due to recent MI
Fundamentals of ECG

T wave
Bundle Branch Block (Left Bundle Branch Block)
Left bundle branch block produces T-wave inversion in the lateral leads I, aVL and V5-6.
Fundamentals of ECG

T wave
Bundle Branch Block (Right Bundle Branch Block)
Right bundle branch block produces T-wave inversion in the right precordial leads V1-3.
Fundamentals of ECG

T wave
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

T wave
Right Ventricular Hypertrophy
Right ventricular hypertrophy produces 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

T wave
Pulmonary Embolism
T wave inversion in the inferior and right precordial leads
 Acute right heart strain (e.g. secondary to massive pulmonary
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

T wave
Pulmonary Embolism
Acute massive PE with SI QIII TIII RBBB TWI V1-3
SI QIII TIII
 Pulmonary embolism may also produce T-wave inversion in lead III as
part of the SI QIII TIII pattern
 S wave in lead I, Q wave in lead III, T-wave inversion in lead III
Fundamentals of ECG

T wave
Pulmonary Embolism
Acute massive PE with SI QIII TIII RBBB TWI V1-3
Fundamentals of ECG

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

T wave
Raised intracranial pressure (ICP)
Events causing a sudden rise in intracranial pressure (e.g.
subarachnoid haemorrhage) produce widespread deep T-
wave inversions with a bizarre morphology.
Fundamentals of ECG

T wave
Biphasic T waves
There are two main causes of biphasic T waves:
 Myocardial ischaemia; Hypokalaemia
The two waves go in opposite directions:
Biphasic T waves due to ischaemia – T
waves go UP then DOWN
Biphasic T waves due to Hypokalaemia
– T waves go DOWN then UP
Fundamentals of ECG

T wave
Wellens Syndrome
 Wellens syndrome is a pattern of inverted or biphasic T waves in
V2-3 (in patients presenting with/following ischaemic sounding
chest pain) that is highly specific for critical stenosis of the left
anterior descending artery.
 There are two patterns of T-wave abnormality in Wellens syndrome:
 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

T wave
Wellens Syndrome (Wellens Type A)
Biphasic T waves with the initial deflection positive and the
terminal deflection negative
Fundamentals of ECG

T wave
Wellens Syndrome (Wellens Type B)
T-waves are deeply and symmetrically inverted
Fundamentals of ECG

T wave
Camel hump’ T waves
• ‘Camel hump’ T waves is a term used by Amal Mattu to describe T-waves that have a
double peak. There are two causes for camel hump T waves:
 Prominent U waves fused to the end of the T wave, as seen in severe
hypokalaemia
 Hidden P waves embedded 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

T wave
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

T wave
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
ischaemia resolves
Fundamentals of ECG

T wave
Flattened T waves
Hypokalaemia
Generalised T-wave flattening in hypokalaemia associated with prominent U waves
in the anterior leads (V2 and V3)
Fundamentals of ECG

Approach to a patient with T wave abnormality in ECG

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Approach to a patient with T wave abnormality in ECG