T wave changes

Diagnosis

Types of T wave morphology

Normal negative T waves in III, AVR and V1 (upright T wave in III is more common).

• Normally upright in 1, 2, V3-V6
• Negative in AVR
• If is greater than 2/3 height of R wave then is abnormal

• Distribution
  • T wave is normally inverted in aVR; sometimes inverted in III, aVF, aVL, V1
• T-wave inversions in V2-V6 are always pathologic
• Morphology
  • Inverted, symmetric,
  • Transient changes suggests ischemia without infarction
  • Persistent changes suggests infarction (troponin elevation usually seen)
• Pseudonormalization
  • In presence of baseline TWI (within 1 month), reocclusion causes normalization of TWI
  • Should be interpreted as evidence of ischemia

Differential Diagnosis

T Wave Inversions

• Normal in pediatrics
• Myocardial infarct (NSTEMI)
• Myocardial ischemia (Wellen's) - T waves go up, then down
• Hypokalemia - T waves go down, then up (or camel humped, one upright TW and upright U-wave in severe hypokalemia)
• Hyperkalemia
• Pulmonary embolism (RV strain)
• Pulmonary hypertension, acute or chronic
• Pulmonary disease - hyperventilation, pneumothorax, pneumonia
• LVH with strain pattern
• RVH
• Bundle branch block (both left and right)
• WPW
• Pericarditis (stage 3)
• CNS T waves (diffuse, deep)
• Arrhythmogenic right ventricular dysplasia (may also have epsilon wave)
• HOCM
• Paced rhythm
• Elevated intracranial pressure

Peaked T-waves

• MI (hyperacute T waves)
• Hyperkalemia
• Benign Early Repolarization
• De Winter's T waves (acute LAD occlusion)

See Also

• ECG Basics