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Giant T waves

Giant T Wave Inversions

Tue, 05/24/2016 - 15:17 -- Dawn

This ECG was obtained from a man in his 70’s.  We have no other clinical information.  It is interesting for several reasons. 

Giant T wave inversions     The most obvious abnormalities we see on first inspection are the deeply inverted T waves in Leads V3 through V6. The T wave in V3 is biphasic. There are also T wave inversions in all of the limb leads except aVR.  The precordial T wave inversions are called “giant T wave inversions” because they are 10 mm or more in depth.  There are many causes of giant T wave inversions, including, but not limited to: myocardial ischemia, coronary artery disease and reperfusion, pulmonary edema, massive pulmonary embolism, subarachnoid hemorrhage, apical hypertrophy, post-tachycardia syndrome, and post-pacing syndrome. 

What else?     There are no Q waves or ST elevations.  The ST segments are not entirely normal in shape, being flattened in most lead.  The frontal plane axis is left.  Even though the ECG almost meets criteria for left ventricular hypertrophy, by exclusion we would call this anterior fascicular block (left anterior hemiblock).   Obviously, it would help greatly if we had some history and clinical information to accompany this ECG. 

Deep, Symmetrical T Wave Inversions

Tue, 12/15/2015 - 21:20 -- Dawn

This ECG is from a 50-year-old man with chest pain.  Unfortunately, we don’t have any other clinical information.   This tracing is a good example of widespread, symmetrical inverted T waves.  Inverted T waves are present in Leads I, aVL, II, and V3 through V6. (The anterior-lateral leads).  There are ST segment elevations in Leads V1 and V2.  

Many conditions can cause inverted T waves, and bedside assessment is necessary to make a certain diagnosis.  Some T wave inversions are benign, such as in persistent juvenile T wave pattern.  Some can be due to life-threatening problems like pulmonary embolism, CNS injury, and cardiac ischemia.  T wave inversions can be secondary to conditions like left ventricular hypertrophy, left bundle branch block, and ventricular rhythms.  When T waves are deep and symmetrical as they are here, they may be a sign of acute coronary syndrome, or cardiac ischemia.  Since we know this patient had chest pain, and there is some ST elevation, this should be considered as a cause for his T wave changes. 

In addition to the dramatic T waves, he also has P waves suggestive of “P mitrale”, or left atrial enlargement.  The P waves in Lead II are wide (about 10 or 11 ms) and just over 1 mv tall. This is “borderline” for most LAE criteria.   The P waves in Lead V1 are biphasic, with the second portion negatively deflected and over 1 mv deep.  Acute myocardial infarction can cause left ventricular dysfunction, which can cause backup pressure to the left atrium. 

Inverted T waves, like all ST and T wave changes, should always be assessed in the context of the patient presentation, history, and previous ECGs, if available. 

References:  Consultantlive.com,   Dr. Ken Grauer

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