Tuesday, July 14, 2015

A 30 year old African American with Chest pain and T-wave Inversion

A 30 yo African American Male presented agitated and with active chest pain, thought to be on a stimulant.  This ECG was recorded:
There is T-wave inversion in II, III, aVF and V4-V6.  What is it?

The patient was sedated and this was recorded 2.75 hours later:
Now there is sinus bradycardia.  The T-wave inversion is now seen in V2 and V3 in addition to V4-V6.  Inferior T-waves are no longer inverted.
Does this change your mind about the first? 

I was shown these ECGs without that information and asked if the patient was African American.  That is because they are classic "Benign T-wave Inversion (BTWI)."

What is particularly interesting here is the 2nd one: there is an apparently long QT interval, large U-waves in V2 and V3, and the development of T-wave inversion in V2 and V3 when it was not there on the previous.

The worry here was that it was Wellens' syndrome.  BTWI has a comparatively short QT.  My hand-measured, Bazett-corrected QTc in both of them is 415 ms.  The apparent increase on the 2nd is because the raw QT is longer, but is limited by the correction.  Wellens' is generally (but not always!) longer.

The giveaways are the tall R-waves in the affected leads, with minimal S-waves, and the presence of J-waves, especially in V3-V6 on the second ECG.  U-waves are a common feature of early repolarization, which is closely related to BTWI.

The really worrisome part is the change.  All I can say is that even normal "baseline" ECGs change from situation to situation.  Early repol is not stable over time.

The patient did indeed rule out for MI.

Here is much more on BTWI.

See especially this post.

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