Pseudonormalization of Inferior T-waves

In a few days I will post a twist on pseudonormalization, but wanted to first post this classic case.

This 49 year old male presented after an episode of chest pain. 

There is sinus rhythm.  There are T-wave inversions in II, III, aVF and V4-V6.  This is consistent with inferior and lateral Wellens' type reperfusion T-waves.  There is also a large upright T-wave in V2 (and, in retrospect) I see this as a posterior reperfusion T-wave. 

The first ECG is consistent with a patient who had an occlusion of an artery supplying the inferior and lateral walls, but is now reperfused.

In the ED, his pain recurred and this ECG was immediately recorded, 20 minutes later:

Now the T-waves are upright (not normal, but pseudonormalized).  This is an obvious STEMI, but nicely illustrates the phenomenon of pseudonormalization.  Lead V5 by itself looks normal unless you compare it to lead V5 20 minutes prior.

Pseudonormalization is a phenomenon or reocclusion of an artery that has recently reperfused.  The reperfusion resulted in inverted T-waves (reperfusion T-waves, Wellens' T-waves).  The reocclusion results in the T-wave becoming upright again.  If seen in isolation, one may be lulled into thinking they are truly normal (see V5).

See here for more cases of pseudonormalization.

This also illustrates the importance of serial ECGs.