Approach to a patient with T wave abnormality in ECG
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This document discusses the fundamentals of electrocardiogram (ECG) interpretation with a focus on T-wave abnormalities, including their characteristics, clinical implications, and various conditions associated with them. It provides detailed case studies demonstrating how specific T-wave patterns relate to medical conditions like hyperkalemia, myocardial ischemia, and different cardiomyopathies. The document emphasizes the importance of recognizing these patterns for accurate diagnosis and management in cardiology.
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 âĸ The T wave is the positive deflection after each QRS complex. âĸ 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 īąCharacteristics of the normal T wave īą Upright in all leads except aVR and V1 īąAmplitude < 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 âĸ Peaked T waves âĸ Hyperacute T waves âĸ Inverted T waves âĸ Biphasic T waves âĸ âCamel Humpâ T waves âĸ 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 âĸ Broad, asymmetrically peaked or âhyperacuteâ T-waves are seen in the early stages of ST-elevation MI (STEMI) and often precede the appearance of ST elevation and Q waves. âĸ 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 âĸ 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. âĸ The normal T wave in V1 is inverted. âĸ An upright T wave in V1 is considered abnormal â especially if it is tall (TTV1), and especially if it is new (NTTV1). īˇ 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: īļ Normal finding in children īļ Persistent juvenile T wave pattern īļ Myocardial ischaemia and infarction īļ Bundle branch block īļ Ventricular hypertrophy (âstrainâ patterns) īļ Pulmonary embolism īļ Hypertrophic cardiomyopathy īļ 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 âĸ T-wave inversions in the right precordial leads may persist into adulthood and are most commonly seen in young Afro-Caribbean women. âĸ 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 âĸ 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 â 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 īˇ Left ventricular hypertrophy (LVH) produces T-wave inversion in the lateral leads I, aVL, V5-6 (left ventricular âstrainâ 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 âstrainâ 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 īˇ Acute right heart strain (e.g. secondary to massive pulmonary embolism) produces a similar pattern to RVH âĸ 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 īˇ Pulmonary embolism may also produce T-wave inversion in lead III as part of the SI QIII TIII pattern īˇ 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: īˇ Myocardial ischaemia; Hypokalaemia The two waves go in opposite directions: Biphasic T waves due to ischaemia â T waves go UP then DOWN Biphasic T waves due to Hypokalaemia â T waves go DOWN then UP Fundamentals of ECG
- 30. drtoufiq1971@gmail.com T wave Professor Dr Md Toufiqur Rahman Wellens Syndrome īą 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. īą There are two patterns of T-wave abnormality in Wellens syndrome: īą Type A = Biphasic T waves with the initial deflection positive and the terminal deflection negative (25% of cases) īą Type B = T-waves are deeply and symmetrically inverted (75% of cases) īą 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 humpâ T waves âĸ âCamel humpâ 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: īˇ Prominent U waves fused to the end of the T wave, as seen in severe hypokalaemia īˇ 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 humpâ 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