I think that QRS axis is +60 and T wave axis is -30 so the difference is 90 ( min 7:00 to 7:30) ? But what is normal range for Axis difference between QRS and T wave and its significance ?
Normal is not easily defined, but as the difference gets larger, the risk gets proportionally larger. > 100 definitely abnormal. My attention is caught if the angle is greater than 60 degrees, but this is not definitely abnormal.
But i know that If QRS-T angle >100 ,It's suspicious for secondary abnormality rather than primary as LVH ,and There is a big chance it’s not a STEMI ? So when to consider QRS/T angle abnormal if more than 100 ?
I was waiting for this kind of lecture since long..THNX U sooo much...My question is in majority of females with or without chest pain we see so many repolarisation abnormalities so calles T wave changes..why so? It unnecessarily ends up investigating further including angio..as they complaints also some kind of non specific chest pain many times...Sir please opine..thanks once again
Only because the usual teaching is that T-wave inversion is ischemia and dangerous, when in fact most is benign. But it is not simple to tell the difference. Takes lots of study and experience.
Hi Dr.med Smith, As I am about to complete my first year of residency (cardiology) I discussed T wave inversions and Wellens Syndrome with my fellow colleagues. One of my colleague is just doing a six month rotation in our Cardiology department and asked an intersting questions. With a patient with Wellens Syndrome, now pain free, after 6h from the first pain episode is it possibile that the high sensible troponins stay negative? In that case (negative high sensisble troponins) should the patients be still sent to the cath lab or sent home and undergo an elective II level imaging test (RM/ TC)? My opinion on the latter is that with a pathological ECG and no clear cause (unseen/unknown wellens ECG pattern) patient should stay hospitalized. I'm interested in what you think about these two questions.
Thank you for your help and congratulations on your excellent blog.
Beltrani, There are many false positive Wellens' (search this blog for PseudoWellens). A lot depends on what you consider "negative" for hs cTnI. Below 99% only? 2 values that are below but have a delta? Or two values that are below the LoD? all very different. Also, what if the T-wave inversion resolves? Such dynamic T-wave inversion is NOT Wellens' but is unstable angina and will often have negative troponins. If it is Wellens', it must evolve (see this: http://hqmeded-ecg.blogspot.com/2011/03/classic-evolution-of-wellens-t-waves.html ). If no evolution, then not Wellens' and negative trops are true negative. I would say if both below LoD, then definitely not Wellens'. If both below 99% and no delta, then almost certainly not Wellens'. But if either is above 99%, or if both below 99% but with a significant delta, it certainly may be Wellens'. Steve Smith
thank you, Steve. at least now i am beginning to see how much more i need to learn. it is funny . in our ER we get handed EKG's to read (from all parts of the ER), regardless sometimes of what else we are doing (i might even be in the lavatory), to just quickly read and mark "no STEMI", based on the standard ST elevation criteria. but as you have shown repeatedly, it is so much more than just 2mm ST elevation in two contiguous leads, (or 1.5 for girls and 2.5 for boys...). and that is what makes it so terribly interesting, and challenging. tom thank you
2:40 "If the voltages are that high we can't diagnose Wellens because it might be a false positive due to LVH" Is there a cutoff to define "high voltages"?
Thanks for the lecture! It definetely shedded some light on my confusion about T wave patterns in ischemia. However I would love to hear an hypothesis regarding WHY does the T wave becomes negative only upon repersion. I am doing a Phd in cellare EP. Electrophysiologically, a discordant T wave means you have an inversion of the normal paatern whereby earlier activates area repolarize after (ie. they a longer action potential duration) the later activates areas (in textbooks, the epicardium). But why would ischemia not produce such a phenomenon during ongoing occlusion? Thanks in advance, I hope my question is clear
There are theories about that, but it is more important to just know that the phenomenon is real. Theories have to do with repolarization dispersal in the ischemic area around the infarct zone
DEAR READER: I have loved receiving your comments, but I am no longer able to moderate them. Since the vast majority are SPAM, I need to moderate them all. Therefore, comments will rarely be published any more. So Sorry.
Fantastic lecture. Thank you. Please record more.
ReplyDeleteJim,
DeleteThanks! Please spread the word.
You can see other lectures posted down the sidebar.
Steve
thanks dr Smith, very interesting and practic information
ReplyDeleteThanks for the feedback, Eduardo!
DeleteI think that QRS axis is +60 and T wave axis is -30 so the difference is 90 ( min 7:00 to 7:30) ? But what is normal range for Axis difference between QRS and T wave and its significance ?
ReplyDeleteNormal is not easily defined, but as the difference gets larger, the risk gets proportionally larger. > 100 definitely abnormal. My attention is caught if the angle is greater than 60 degrees, but this is not definitely abnormal.
DeleteBut i know that If QRS-T angle >100 ,It's suspicious for secondary abnormality rather than primary as LVH ,and There is a big chance it’s not a STEMI ?
DeleteSo when to consider QRS/T angle abnormal if more than 100 ?
No good data. Large QRST angle does not imply STEMI. greater than 100 I would always consider abnormal. What it indicates depends on many factors.
ReplyDeleteI was waiting for this kind of lecture since long..THNX U sooo much...My question is in majority of females with or without chest pain we see so many repolarisation abnormalities so calles T wave changes..why so? It unnecessarily ends up investigating further including angio..as they complaints also some kind of non specific chest pain many times...Sir please opine..thanks once again
ReplyDeleteOnly because the usual teaching is that T-wave inversion is ischemia and dangerous, when in fact most is benign. But it is not simple to tell the difference. Takes lots of study and experience.
ReplyDeletethank you doctor
ReplyDeletehello
ReplyDelete8:53 28/F with anxiery and CP... any comments on lead 1 T wave in both ECGs??
I think they are within normal limits
Delete40:08.... which wall is involved?????????
ReplyDeleteInferior and posterior
DeleteHi Dr.med Smith,
ReplyDeleteAs I am about to complete my first year of residency (cardiology) I discussed T wave inversions and Wellens Syndrome with my fellow colleagues.
One of my colleague is just doing a six month rotation in our Cardiology department and asked an intersting questions.
With a patient with Wellens Syndrome, now pain free, after 6h from the first pain episode is it possibile that the high sensible troponins stay negative?
In that case (negative high sensisble troponins) should the patients be still sent to the cath lab or sent home and undergo an elective II level imaging test (RM/ TC)?
My opinion on the latter is that with a pathological ECG and no clear cause (unseen/unknown wellens ECG pattern) patient should stay hospitalized.
I'm interested in what you think about these two questions.
Thank you for your help and congratulations on your excellent blog.
Dr.med Beltrani Vittorio
Cardiocentro Ticino
Swtizterland
Beltrani,
DeleteThere are many false positive Wellens' (search this blog for PseudoWellens). A lot depends on what you consider "negative" for hs cTnI. Below 99% only? 2 values that are below but have a delta? Or two values that are below the LoD? all very different. Also, what if the T-wave inversion resolves? Such dynamic T-wave inversion is NOT Wellens' but is unstable angina and will often have negative troponins. If it is Wellens', it must evolve (see this: http://hqmeded-ecg.blogspot.com/2011/03/classic-evolution-of-wellens-t-waves.html ). If no evolution, then not Wellens' and negative trops are true negative. I would say if both below LoD, then definitely not Wellens'. If both below 99% and no delta, then almost certainly not Wellens'. But if either is above 99%, or if both below 99% but with a significant delta, it certainly may be Wellens'.
Steve Smith
Thank you for your precise and enlightening answer.
DeleteBest Regards,
Dr.med Beltrani
thank you, Steve. at least now i am beginning to see how much more i need to learn. it is funny . in our ER we get handed EKG's to read (from all parts of the ER), regardless sometimes of what else we are doing (i might even be in the lavatory), to just quickly read and mark "no STEMI", based on the standard ST elevation criteria. but as you have shown repeatedly, it is so much more than just 2mm ST elevation in two contiguous leads, (or 1.5 for girls and 2.5 for boys...). and that is what makes it so terribly interesting, and challenging.
ReplyDeletetom
thank you
Thanks, Tom.
DeleteSteve
Hello doctor.. Any links to your blog which talks more about QRS/T angle and its significance?
ReplyDeleteThanks
Sorry, not much else.
DeleteTry this: https://scholar.google.com/scholar?hl=en&as_sdt=0%2C24&q=QRST+angle+ekg&btnG=
2:40 "If the voltages are that high we can't diagnose Wellens because it might be a false positive due to LVH" Is there a cutoff to define "high voltages"?
ReplyDeleteI wish I could tell you a number! no research on that.
Deleteany pdf version of this wonderful lecture?
ReplyDeleteI have not made one, but that's a good idea. I'll try to get around to it.
DeleteThank you Dr. Smith for all the great lectures, discussions and ECG cases.
ReplyDeletethank you very much for this amazing lecture, hope to see more like these..
ReplyDeleteThanks for the lecture!
ReplyDeleteIt definetely shedded some light on my confusion about T wave patterns in ischemia. However I would love to hear an hypothesis regarding WHY does the T wave becomes negative only upon repersion. I am doing a Phd in cellare EP. Electrophysiologically, a discordant T wave means you have an inversion of the normal paatern whereby earlier activates area repolarize after (ie. they a longer action potential duration) the later activates areas (in textbooks, the epicardium). But why would ischemia not produce such a phenomenon during ongoing occlusion? Thanks in advance, I hope my question is clear
Thanks for your lecture! I am curious to learn what is in your opinion the mechanism whereby the T wave only become negative after reperfusion occurs.
ReplyDeleteThere are theories about that, but it is more important to just know that the phenomenon is real. Theories have to do with repolarization dispersal in the ischemic area around the infarct zone
Delete