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Ischemia

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

Inverted T waves in Lateral Wall

Tue, 11/10/2015 - 20:45 -- Dawn

This ECG was obtained from a 49-year-old man who was a patient in an Emergency Dept.  We do not know his presenting complaint, only that he had a history of insulin-dependent diabetes mellitus (IDDM).  It was noted by the donor of the ECG that the patient had no chest pain, no shortness of breath, and no other cardiac symptoms.  We do not know his hydration or electrolyte status.  There are quite a few interesting abnormalities on this ECG, and the exact interpretation would, of course, depend upon the patient's clinical status.  It would definitely help to be there!

First, we note a sinus tachycardia at a rate of 118 bpm.  This could be due to very many causes, including but not limited to:  dehydration, pain, anxiety, high or low blood glucose, fever, or CHF.  The PR and QT intervals are within normal limits.  The QRS complexes are narrow.  The axis is normal at 0 degrees.  The QRS voltage in the lateral leads is on the high side of normal, but we do not know this patient's body type.  Voltage as read by the ECG can be influenced by a thin chest (making voltage look larger) or a large chest (making voltage lower).

There are T wave abnormalities in the lateral leads:  I, aVL, V5 and V6.  The T waves are inverted, which can have many meanings.  However, when inverted T waves are in the lateral leads, as opposed to the inferior or right chest leads, it is often a sign of ischemia.  The flat, horizontal ST segments can also signify coronary artery disease (CAD).  This patient denied cardiac symptoms, but his age and history of IDDM make it probably that CAD is a factor.  The leads with T wave inversion also have a small amount of ST segment depression.  The right precordial leads, V1 and V2, have a small amount of ST elevation,  This possibly represents a reciprocal change to the ST depression in V5 and V6.

Because we are not at the bedside of this patient, there are many details we do not know.  But these inverted T waves could be ischemic T waves, and this requires that the patient be further evaluated.

As always, we welcome comments, as this ECG probably has more to say!

 

REFERENCES:  Dr. Ken Grauer,  Life In The Fast Lane, World Journal of Cardiology 

Lateral Ischemia and Previous MI In a Patient With Chest Pain

Mon, 01/09/2012 - 22:48 -- Dawn

During our summer break, we are reprising a few of the best ECGs from our archives, to give you a chance to comment or to ask questions.

This ECG was taken from a 52 year old man who was complaining of chest pain, with a history of severe multi-vessel disease. He has a history of M.I. and states he has five coronary stents.

His pain was partially relieved by Ntg., and he was given aspirin in the field, and then IV Ntg., Integrelin, and morphine before being sent to the cath lab. This ECG shows T wave inversions with coved upward ST segments, but no ST elevation in the lateral leads: I and aVL, and the anterior-lateral leads, V3 through V6. This represents the territory covered by the left coronary artery, and points to a lesion in the proximal portion of the artery. Also in this ECG are pathological Q waves in right side leads, III, V1 and V2.

In the cath lab, he was discovered to have a ruptured plaque in the proximal LAD, with some blood getting through a very narrow channel. He was referred for coronary artery bypass surgery the next day.

Coronary Artery Disease

Mon, 10/31/2011 - 13:11 -- Dawn

This ECG was taken from a 49 year old man with insulin-dependent diabetes, with no complaints of cardiac symptoms.  The rest of this patient's history is lost.   This is a great ECG for demonstrating the flat ST segments and T wave inversion of ischemia due to coronary artery disease. The ECG changes are very noticeable in the lateral wall.  It is not known why the patient presented with sinus tachycardia.

 

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