Saturday, August 27, 2011

Reversible T-wave inversion -- it reverses, then evolves, then reverses when ischemia is gone. Normalization of T-waves, NOT pseudonormalization.

A 62 yo male has had chest pain with exertion for 2 weeks.  He began having chest pain at rest at 2AM, and presented at 7 AM.

Here is his initial ECG:

Sinus rhythm.  There is a QS-wave in V2 (old MI?) and very subtle terminal T-wave inversion in V3, and ST depression in V4-V6, highly suspicous for LAD NonSTEMI.  I believe the extra wave in V1-V3 is artifact. 

This was recorded 2 hours later, after troponin I confirmed acute MI at 0.485 ng/mL:

There is a PVC, but now the terminal T-wave inversion is gone. Some ST depression in V5 and V6 remains.

An angiogram revealed 3-vessel disease and a 90% LAD stenosis, 99% RCA, and 70% ostial right Posterior Descending Artery.  No intervention was done because of consideration of CABG.

This was recorded 9 AM the next day.  A simultaneous echo had very subtle WMA in the LAD territory.
Now there is classic biphasic terminal T-wave inversion (strictly speaking, it is not Wellens' because Wellens' requires preservation of R-waves). There is also subtle new Terminal T-wave inversion in aVF ("inferior Wellens").

On day 2, PCI of the rPDA and RCA was done.  The troponins continued to trend down.  
This ECG was recorded the next AM (day 3):
There is evolution of anterior T-waves, with T-wave inversion in V4 more pronounced now.  T-wave in aVF is now upright.

On day 3, he had the LAD stented.  Troponins bumped to 3.0 mcg/L after the PCI.   This was recorded the next AM:
Now, the anterior T-waves have completely normalized.
Such reversal is usually due to reocclusion (pseudonormalization) and associated with chest pain.  Wellens in the setting of significant troponin elevation usually evolves to deep and symmetric T-waves, then normalizes over weeks to months.  This is an unusual case of T-wave normalization without re-occlusion that occurred in 24 hours.

In unstable angina, with no myocardial cell death, T-waves are more likely to normalize when ischemia is resolved.

Contrast this normalization of T-waves to the pseudonormalization of the last post.


  1. Hello Dr. Smith,

    The patient seems to have LVH (S2+R5 >35mm). Did he have any underlying cardiomyopathy? Also the last ECG shows what I believe is STD in the inferior leads. Is this do to the stenting?



  2. Indeed he does meet criteria for LVH. The ST depression is there to some degree on all the EKGs. Now I've lost his I.D. and can't look up whether he had a proximal LAD occlusion (to account for inferior ST depression), or cardiomyopathy (I'm all but certain he did not). The voltage without the typical repolarization abnormalities of severe LVH is probably not significant.


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