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T Wave Inversion

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Dawn's picture

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. 

Dawn's picture

Recent M.I.

Wed, 04/20/2016 - 23:07 -- Dawn

This ECG is from a 54-year-old woman who had an M.I. one week prior to this tracing.  She did not receive interventional treatment, as it was not available where she lived when this happened years ago.  Her ECG shows the signs of healing injury, as well as probable permanent damage. 

Where was this M.I.?      The affected leads are all of the precordial leads (V1 through V6), as well as I and aVL.   The precordial leads reflect the anterior and low lateral walls of the heart, and Leads I and aVL show us the high lateral wall.  This area is perfused by the left coronary artery, and she had a proximal lesion. 

What ST and T wave changes are present?    All of the leads listed above show a flattening of the ST segments.  While they are no longer elevated (the acute injury is over), they are flat and almost convex upward.  This shape is usually abnormal, and it has persisted even though the acute injury is subsiding.  The T waves in the anterolateral leads are all inverted.  This represents reperfusion of the injured tissue.  Whether the offending clot is removed by invasive procedure, thrombolytic drugs, or natural degradation, the tissue that is still alive will reperfuse. 

Dawn's picture

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:,   Dr. Ken Grauer

Dawn's picture

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 

Dawn's picture

Anterior Wall M.I.

Sun, 07/26/2015 - 13:10 -- Dawn

This is a very interesting ECG taken from an acute M.I. patient.  Your basic level students will be able to appreciate the ST elevation in V1 through V3. Although the elevations are not very high, there are plenty of other abnormalities that point to acute STEMI: the ST segments are flat and there are marked ischemic T waves in the lateral leads: V4 through V6 and I and aVL.  The patient was suffering an acute episode of chest pain.

It is also noticeable that R wave progression in the precordial leads (V1 through V6) is not optimal, as there is still a significant S wave in V6.  We do not know if this is an electrode placement issue or not.  The QT interval is just at the high limit of normal.  
For your more advanced students, aVR has ST elevation.  It is not reciprocal of an ST depression in Lead II.  Research has shown that ST elevation in aVR and V1, especially when the ST elevation is greater in aVR, is a strong indication of proximal LCA or a Left Main occlusion.  Unfortunately, we do not have cath results for this patient.  In acute M.I. patients,  higher mortality rate has been associated ST elevation in aVR.

For more information about ST elevation in aVR, click here:

and here:


Dawn's picture

Teaching Series 1113: ECG 6 of 6 - Acute Anterior Wall M.I.

Sun, 12/15/2013 - 20:25 -- Dawn

This ECG is the last in a series of 6 that were donated by Jenda Enis Štros showing the evolutionary changes of an M.I. from onset, through spontaneous reperfusion, angioplasty, re-occlusion by thrombus, and recovery.  This ECG shows deep precordial T wave inversions, an expected evolutionary change after reperfusion of an occluded artery - in this case, the left anterior descending.  The patient has lost some of his QRS amplitude (viable heart muscle), but has not developed pathological Q waves.  Pathological Q waves would indicate full-thickness necrosis of the wall, which is usually a permanent injury.  

The patient was discharged home with a 45% ejection fraction (60% is ideal), and he had akinesis of part of his anterior wall.  This can be permanent or temporary, and followup studies would be needed to evaluate the ongoing health and function of the left ventricle.

Here are links to all six ECGs from this series:



Dawn's picture

Teaching Series 1113: ECG 4 of 6 - Acute Anterior Wall M.I.

Sun, 12/15/2013 - 20:07 -- Dawn

Continuing our teaching series of ECGs donated by Jenda Enis Štros, ECG 4 of 6 shows a new occurance of huge T wave inversions in the precordial leads.  Since this is the area that was stented (left anterior descending artery, anterior wall of the LV), we immediately should think of re-occlusion of the artery.  In a newly-placed stent, the danger is thrombosis (blood clot).  The patient had no chest pain at this time.

Here are links to all six of the ECGs in this series:


Dawn's picture

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.

Dawn's picture

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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