Sunday, December 19, 2010

ECG Interpretation Review - #5 (T Wave Inversion, Ischemia, Juvenile T Wave Variant)

QUESTION: Interpret the 12-lead ECG below.
  • Clinically  How would you interpret the anterior T wave inversion (arrows) if this ECG was obtained from a middle-aged adult with chest pain?  Are these changes likely to be acute?
  • How would you interpret this same ECG if instead it was obtained from a healthy 5 year-old?
Figure 1 (ECG reproduced from ECG-2014-ePub )
Note - Enlarge by clicking on Figures -
INTERPRETATION:  The rhythm is sinus arrhythmia at a rate between 60-70/minute. All intervals (PR, QRS, QT) are normal.  There is RAD (Right Axis Deviation) with a mean QRS axis of about +100 degrees. There is no chamber enlargement.
  •  Q-R-S-T Changes: There are small Q waves in the inferolateral leads. R wave progression is normal (with transition occurring between leads V3-to-V4).  Assessment of ST-T wave changes reveals deep symmetric T wave inversion in the anterior precordial leads (arrows in V1,V2,V3).
COMMENT: Symmetric T wave inversion will often be seen in the anterior leads (V1,V2,V3 and even up to V4) of pediatric patients.  In an otherwise healthy child (with no heart murmur this finding represents a benign normal variant (referred to as a "Juvenile" T Wave Pattern).  However, the same ECG (with identical T wave inversion) would have to be interpreted very differently IF the patient in question was an older adult with chest pain (in which case ischemia would be suggested).
  • PEARL: Shape of the ST-T wave segment often provides an important clue to clinical significance (Figure 2). Thus, in an older adult with chest discomfort  symmetric T wave inversion (as highlighted by arrows in Figure 1 ) suggests ischemia
  • In contrast  asymmetric ST depression (left panel in Figure 2 ) is much more suggestive of "strain" that accompanies LVH.
Figure 2 - T Wave Morphology - 'Strain" vs Ischemia.
(ECG reproduced from ECG-2014-ePub )
BOTTOM Line:  Interpretation of the ECG shown in Figure 1 can not be done without provision of at least a brief clinical scenario.
  • Scenario #1 (the patient is a healthy 5-year-old with no heart murmur in which case sinus arrhythmia, RAD of this degree, and symmetric T wave inversion in leads V1,V2,V3 are all within the range of normal for the age of the child.
  • Scenario #2 (the patient is a middle-aged adult with chest pain in which case one has to be concerned about the possibility of ischemia.  More history and comparison with prior tracings would be needed to determine if these changes are likely to be acute.
NOTE The Descriptive Analysis for our interpretation is the same in both clinical scenarios (ie, "sinus arrhythmia, RAD, symmetric T wave inversion in V1-to-V3" )  but our Clinical Impression will be very different depending on whether the patient is a healthy child or an adult with chest pain!
  • P.S. The ECG in Figure 1 might yet be interpreted differently if we had but another setting (ie, ongoing shortness of breath of uncertain etiology). In this instance  one would have to consider pulmonary embolism (despite the relatively slow heart rate) in view of: i) RAD; plus ii) Anterior symmetric T wave inversion, which could be a manifestation of acute right heart "strain" (sometimes seen with acute PE).

NOTE:  For more on PJTWP (Persistent Juvenile T Wave Pattern) — including distinction between PJTWP vs other potentially serious conditions:
  • Please check out the Steve Smith ECG Blog post on PJTWP by Brooks Walsh/Steve Smith/Ken Grauer (Jan. 7, 2015). 


  1. How likely is it that an inverted t wave is an artifact if it was seen in a healthy middle aged female with no cardiac history, prior normal ECG

  2. @ Marcus. Thank you for your comment. I would not call this an "artifact" - since the T wave inversion we are seeing IS real. So my interpretation regardless of whether this is a child or an otherwise healthy middle-aged woman with no cardiac history is the same = symmetric T wave inversion in V1-thru-V3. However my Clinical Impression would be different. Although a "real finding" - T inversion in an asymptomatic adult woman is NOT necessarily ischemic. Clinical correlation is needed to know what to do with this finding. Would be different if she was short of breath or having anginal chest pain. If she is truly asymptomatic and has a normal exam - then it may be that not much (if anything) need be done. Clinical correlation will be the key! (But I'd take a truly careful history to be sure there were not "anginal-equivalent" symptoms. THANKS again for your comment!

  3. if there is t wave inversion in V3 V4 V5 and also in AVL thn wht culd be the prognosis???

  4. @ Halima - By asking about T wave inversion in leads aVL + V3,V4,V5 - you are asking about an entirely different tracing than the one posted in this blog. As a result - my answer would be, "It depends" (ie, it depends on the clinical scenario = age of patient, history + the actual ECG itself, as it is impossible to answer this question without seeing the actual tracing). Hope that helps - THANKS for your interest!

  5. I heard that T wave inversion in leads V2-V4 is the range of normal, in black people, is that correct ?

  6. In general — T wave inversion should not persist through to lead V4 in adults ... That said — there are a number of repolarization variants that aren't "normal" — but which may not necessarily reflect pathology. And there is also a "persistent juvenile pattern" that may be seen on occasion in adults (esp. young adult women) — but we would need to see the specific ECG and know the clinical scenario in order to say more ... THANKS for your interest — :)

  7. Hi Ken, and thanks again for your work.
    Wouldn't you write down on your descriptive analysis the possibility of a posterior left fascicular block? If not, why wouldn't you?
    Niko G

    1. Thanks for your comment Niko. I agree that QRS morphology in leads I,II,III is consistent with LPHB. But LPHB is rare as an isolated conduction defect. So in an otherwise healthy young child, I prefer to simply right RAD ( = right axis deviation), since that chance of this being a true isolated LPHB is rare in that setting. In an older adult — it would be fine to add "LPHB" — though once again if no history of ischemia/infarction — isolated LPHB is rare in someone without underlying heart disease. Hope that explains your question.