Approach to a patient with T wave abnormality in ECG
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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. 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. Case: A 25 years old gentleman presented with chest pain and fever .He was normotensive, non-smoker and non-diabetic. His pulse 128b/min and BP-130/80 mm Hg. Troponin I was normal. 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.
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Approach to a patient with T wave abnormality in ECG
- 1. 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
- 2. 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
- 3. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman Fundamentals of ECG
- 4. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 5. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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.
- 6. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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.
- 7. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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.
- 8. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 9. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman Fundamentals of ECG Peaked T waves Tall, narrow, symmetrically peaked T-waves are characteristically seen in hyperkalaemia
- 10. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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.
- 11. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 12. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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).
- 13. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 14. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 15. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 16. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman Myocardial Ischaemia and Infarction Inferior T wave inversion due to acute ischaemia Fundamentals of ECG
- 17. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman Myocardial Ischaemia and Infarction Inferior T wave inversion with Q waves – prior myocardial infarction Fundamentals of ECG
- 18. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman Myocardial Ischaemia and Infarction T wave inversion in the lateral leads due to acute ischaemia Fundamentals of ECG
- 19. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman Myocardial Ischaemia and Infarction Anterior T wave inversion with Q waves due to recent MI Fundamentals of ECG
- 20. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 21. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 22. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 23. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 24. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 25. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 26. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman Pulmonary Embolism Acute massive PE with SI QIII TIII RBBB TWI V1-3 Fundamentals of ECG
- 27. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman Hypertrophic Cardiomyopathy (HCM) Hypertrophic Cardiomyopathy is associated with deep T wave inversions in all the precordial leads. Fundamentals of ECG
- 28. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 29. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 30. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 31. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman Wellens Syndrome (Wellens Type A) Biphasic T waves with the initial deflection positive and the terminal deflection negative Fundamentals of ECG
- 32. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman Wellens Syndrome (Wellens Type B) T-waves are deeply and symmetrically inverted Fundamentals of ECG
- 33. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 34. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 35. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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
- 36. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman 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