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

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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

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

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

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

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

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

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: 638-643

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

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

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

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

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

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

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

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

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

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.

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

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)

CNS T Wave Inversions Deeply inverted Widely splayed Asymmetric ST elevation

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

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

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

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

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

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

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

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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