Sunday, May 1, 2016

10 Cases of Inferior Hyperacute T-waves

In the last post, I showed: 

Ten (10) Examples of Hyperacute T-waves in Lead V2 (a few in V3), due to acute LAD occlusion

Today, 10 examples of inferior hyperacute T-waves.

Details in every case make it even better, so click on the link!!

Case 1.  

Chest Pain in a 61 year old male. Inferior STEMI without inferior ST elevation.

In this case, the followup ECG is diagnostic because of lead V1

Case 2.

Inferior Hyperacute T-waves

Case 3.

Chest Pain in a Male in his 20's; Inferior ST elevation: Inferior lead "early repol" diagnosed. Is it?

This case was missed.  Read about it.

Case 4.

Series of Prehospital ECGs Showing Reperfusion

This has an incredible sequence of ECGs!

Case 5.

The development of an inferior-posterior STEMI, from prehospital to hospital

Case 6. 

Friday's post produced skeptics.....

This case made a lot of readers angry, denying that these are hyperacute Ts

Case 7.

A Case of Clinical Unstable Angina in the ED

This case shows how hyperacute is only relative to the baseline T-waves.  Also, the critical role of reciprocal ST depression and T-wave inversion in aVL.

Case 8.

Is this STEMI? Pattern Recognition is Key 

Go to the link, and this case shows an inferior pseudoSTEMI for contrast

Case 9.

Inferior hyperacute T-waves. The clue is T-wave inversion in aVL. Serial ECGs evolve to ST Elevation.

Case 10.

Subtle Inferoposterolateral STEMI


  1. THANKS to Dr. Steve Smith for providing us with 10 more tracings for teaching the concept of recognizing hyperacute ST-T wave changes in inferior leads (to complement his recent excellent post showing 10 examples of anterior hyperacute T waves).

    Confidence in recognizing this KEY concept becomes easier by review of readily available multiple examples — which can easily be accomplished on this (and Dr. Smith’s other) Blog by clicking on 1 tracing (best to view on a computer rather than the small screen of a smart phone) — and then simply advancing the arrow on your keyboard to rapidly go through the tracings. Embed in your mind which specific features are the definitive clues in each case for a patient with worrisome chest pain that should suggest an acute stemi is evolving. Dr. Smith provides links with detailed case studies and answers. Some of these tracings are easier than others to recognize — especially when additional clues are provided in the chest leads. But virtually ALL have the essential “pattern recognition clue” that one or more inferior T waves just “don’t fit” (ie, they are taller, wider-at-the-base, and/or “fatter-at-the-peak” than they should be given the accompanying QRS complex in the same lead) — WITH unmistakeable mirror-image features seen in leads III and aVL.

    For example, if there is any doubt that the T wave in lead III of ECG #1 is hyperacute — it shouldn’t take more than a glance at lead aVL to recognize a perfect “mirror image” of what we see for the ST-T wave in lead III. Confirmation that this is real comes from similar reciprocal change to aVL in lead I. Extra clues are obviously present in ECG #1 in the chest leads (ie, leads V3,V5,V6).

    #ECG #2 is more subtle — but the T wave peak is “fatter-than-it-should-be” in each inferior lead with reciprocal change in lead aVL. As an example of how carefully one needs to look — the straight ST segment prior to a more-pointed-than-it-should-be T wave in V2 supports posterior involvement in ECG #2.

    A similar “theme” is seen in ECGs #3,4,5,6 — and in the last few tracings shown here.

    ECG #7 is worth special mention. The abnormality in the limb leads did not jump out at me until I clicked on this tracing to magnify it.
    Although admittedly subtle — in the context of a patient with new chest pain — the T wave in lead III looks a bit fatter-than-it-should-be at its peak — AND — there is subtle suggestion of reciprocal change in lead aVL. In this context — the T in lead aVF is also a bit fatter-than-it-should-be — and in the chest leads there is subtle-but-real ST straightening in leads V2,V3. None of this is definitive — but it should clearly increase one’s suspicion and place the onus of immediate close follow-up on the provider to determine if the above are subtle signs of ongoing infero-postero stemi.

  2. I 've seen a patient with an ECG similar to case 8

    The patient was about to be given fibrinolytic
    I remembered your case
    It was so helpful

    Thanks ;-)


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