What makes a T-wave Hyperacute? And: 30 Examples of Hyperacute T-waves, 10 in each of 3 myocardial territories.

Pendell and I and the geniuses at Powerful Medical (Producers of the PMCardio Queen of Hearts OMI AI app) are working on an objective, mathematical definition of hyperacute T-waves, based on real OMI outcomes and hyperacute T-wave annotation that has excellent interrater agreement (between me and Pendell), and it will end up being a logistic regression using these 3 variables: 

1) area under the curve (AUC) relative to the QRS size

2) increased symmetry, as defined by time from T-wave onset to peak compared to time from T-wave peak to T-wave end.

3) some measurement of ST upward concavity (the less concave, the more likely to be HATW

4) The variables and formulas will be different for precordial leads vs. limb leads

 

The Queen of Hearts is exceptional at recognizing hyperacute T-waves.

But you should be also.

The way to get good at it is to see a lot of them, and also see a lot of fake HATWs (mimics)

Here is a difficult pair of ECGs that demonstrate a difference:

One ECG is normal variant STE.  

The other is STE from Acute Anterior (LAD) OMI.  

Which is which?

The answer lies mostly in T-waves and in QRS amplitude

The top T-waves in V2, V3 (A) have a smaller T-waves, but they are the hyperacute ones!! 

Why?  

They are much larger, as measured by area under the curve, in proportion to the small QRS.

The bottom T-waves in V2, V3 (B) are very large, but the QRS is much larger than in (A).  

They have slow upstroke to the peak, and a rapid downstroke, creating assymetry. 

They also have more upward concavity

Many examples of Hyperacute T-waves:

10 Cases of Inferior Hyperacute T-waves

10 Cases of Hyperacute T-waves in V4-V6

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

Here's Case 2 from Inferior Hyperacute T-waves:

For a preview of our upcoming research, here is an image of the median beat of the inferior OMI ECG above, along with a HATW overlay that highlights T waves that meet one of our early definitions, requiring BOTH: 

1) increased T wave area / QRS amplitude, and 

2) increased T wave symmetry defined by position of the T wave peak along the whole T wave.

The early HATW model correctly identifies the HATWs in the inferior leads.

The two measures in each lead are:

1) the result of the T wave area (units mV x msec) / QRS amplitude (units mV), and 

2) the position of the T-wave peak, from 0 to 100% of the T wave interval. 

It could be argued that V6 might also be hyperacute, and it is quite close to the thresholds for the values, but in our initial stages we are prioritizing specificity.

3) We do not show the upward concavity measurement technique here.

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MY Comment, by KEN GRAUER, MD (11/27/2024): 

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For optimally time-efficient identification of acute OMI in the absence of frank ST elevation — it's essential to get good at recognizing hyperacute T waves.

• "A picture is worth 1,000 words". In today's post — Dr. Smith simply provides links to a series of such pictures for us to embed in our memory. Doing so literally enables those of us who embrace the OMI Paradigm the ability to recognize within seconds that a patient with new CP (Chest Pain) — and — one or more hyperacute T waves — needs prompt cath regardless of potential absence of STEMI criteria.
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• NOTE: It is guaranteed that rapid-fire review of these 30 examples will enhance your appreciation for how to recognize acute OMIs long before those of your colleagues who remain "stuck" on the old STEMI paradigm arrive at a similar conclusion (if they ever arrive there ...).

In Figure-1 is the ECG from the August 26, 2009 post in Dr. Smith's ECG Blog (this being one of the 10 Cases of Inferior HATWs that Dr. Smith links to — and the ECG for which he gives a preview of the HATW model that he and Dr. Meyers are working on). Below I note my "qualitative" assessment of this tracing (which QOH will be assisting us in the near future with her data-based analytical interpretation).

• In this patient with new CP — Aren't the T waves highlighted by RED arrows disproportionately enlarged? ("fatter"-at-their-peak and wider-at-their-base than they should be, given size of the QRS in these leads).
• Compare this relative disproportion of T waves in the inferior leads — to the proportions of QRS and T wave in lead V6 of this tracing. Any difference?
• Confirmation that the extra "bulkiness" of these inferior lead T waves is "real" — is forthcoming from disproportionate reciprocal enlargement of the T wave inversion in lead aVL (that is almost large enough to "swallow up" the tiny QRS in lead aVL).
• In Figure-1 — Since this patient is having new CP, this T wave disproportionality in 4 of the limb leads by definition represents hyperacute T waves that mandate prompt cath. With practice — the need for prompt cath should take your "knowing eyes" no more than seconds to recognize!
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• P.S.: The more abnormal leads and lead areas you can identify in a given ECG — the more solid the evidence of acute OMI becomes. Much more subtle (but still definitely present) in this 2009 case — is the lack of even slight ST elevation that we normally see in leads V2 and V3 (as well as some very subtle ST segment straightening in V2). While it would be difficult to be certain of this very subtle ECG finding by itself — in the context of definitely hyperacute T waves in leads II,III,aVF and aVL — I interpreted the lack of any ST elevation in V2,V3 as consistent with associated posterior OMI.

Figure-1: ECG from the August 26, 2009 post in Dr. Smith's ECG Blog.

Another Example

As a 2nd example from previous posts illustrating rapid recognition of hyperacute T waves — Consider the comparison picture in Figure-2 (taken from My Comment in the September 27, 2024 post written by Dr. Jesse McLaren).

• The ST-T waves for leads V3,V4 on the left in Figure-2 (GREEN border leads) — are from a normal tracing. There is slight J-point ST elevation, with a gently upsloping ST segment that ends with a slender, upright T wave.
• The ST-T waves for leads V3,V4 on the right in Figure-2 (RED and BLUE border leads) are from a patient with new CP.

QUESTION:

• Why are the ST-T waves on the right in Figure-2 clearly hyperacute?

Figure-2: Comparison of normal vs hyperacute ST-T waves (from My Comment in the September 27, 2024 post in Dr. Smith's ECG Blog).

ANSWER to Figure-2:

• In contrast to the normal ST-T wave appearance in the GREEN border leads — is the appearance of the ST-T waves from leads V3,V4 of the patient with new CP. Aren't these ST-T waves within the RED and BLUE rectangles clearly more "bulky", with a much wider T wave base than would be expected given modest QRS amplitude in these leads?
• In this patient with new CP — these are hyperacute T waves suggestive of OMI until proven otherwise. Total Time needed to recognize these hyperacute T waves should be no more than seconds!
• For details on this case — CLICK here — September 27, 2024 —