Monday, June 1, 2015

A Young African American Woman with Chest Pain and Precordial T-wave Inversions.

An African American woman in her late 20's presented with sudden onset of dull/aching left chest pain, with associated SOB and dyspnea on exertion.  She reported similar symptoms in the past associated with anxiety.

Here is her ED ECG:
There are inverted T-waves in V1 (always normal) but also V2 and V3 (unusual).  In this case, they are classic for "persistent" juvenile T-waves (PJTW).  The T-wave inversions are shallow, asymmetric (slow downstroke, more rapid upstroke) and occur most commonly in young women of African descent. 

The exam was non-contributory.  A d dimer was normal.  She continued to have pain and so another ECG was recorded 3 hours after first:
There are minor differences which are not pathologic.  It continues to be very typical of Persistent Juvenile T-waves.

She has serial contemporary troponins drawn for 9 hours, all were below the level of detection.

This is a typical case of "Persistent" Juvenile T-waves.

Here is a previous in-depth post by Brooks Walsh and me on PJTW.

Brooks and I have submitted a paper showing how these T-waves are not necessarily "persistent".  They may or may not be stable over time.  There is no good evidence to show that they did not become upright and then invert again.

Beware right precordial T-wave inversions in patients who have apparent cardiac syncope, as these may be the only finding of right ventricular cardiomyopathy ("RV Dysplasia").

Here are some more great examples of PJTWP on Pierre Taboulet's fabulous French site.

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