Monday, December 5, 2016

Right Precordial T-wave Inversion

This was posted on Facebook EKG club by Massimo Bolognesi, from Italy.  He is a highly respected Sports Medicine Cardiologist.

He graciously allowed me to re-post it here.

"This ECG was recorded on an asymptomatic 50 year old marathon runner who presented for pre-participation screening."

(This ECG could easily be seen in an ED chest pain patient, and I have seen many)

What do you think?

Sinus bradycardia.
There is high voltage.
There is ST elevation in V2 and V3
There are inverted T-waves in V2 and V3
There are prominent U-waves in V2 and V3

Many responders were worried about ischemia or hypertrophic cardiomyopathy.

Here was Massimo's response:

"I'm very sure of Early Repolarization (ERP) diagnosis in this case. 
First because I have a good eye on ECGs of endurance athletes
Second because I see a lot of these tracings
Third because the stress test determines the disappearance of ECG abnormalities found at rest
Fourth because the echocardiogram is normal
Fifth and last, the clinical presentation speaks clearly."  


I (Smith) have seen many similar ECGs in ED chest pain patients.  I have always believed them to be benign for the reasons described below.  But I have never had any data to support my beliefs, so I've never posted them.

Notice also that the QTc is very short. First, one must realize that the last wave is a U-wave, which is common in ERP.  So the QT must not be measured in V2 or V3.  The QT as measured in other leads is about 420 ms, with a preceding RR of 1500ms, resulting in a Bazett corrected QT interval of 345 ms. This short QT at least makes ischemia all but impossible.  ERP is, of course, associated with an increased long term risk of sudden death, but only marginally and only if in inferior or lateral locations

In addition, many readers of this Facebook post were worried about ischemia, including Wellen's syndrome ("What if this patient had presented with chest pain?"): 

Even in the setting of ischemia, the ischemia would not be represented by this ECG. This is a classic pattern and the QT is so short as to make ischemia very unlikely.  This is a normal variant.  I have seen this innumerable times in chest pain patients in the Emergency Department. At first glance, it may appear to be similar to ischemic T-waves, but it is not. The large upright U-wave, this high voltage, and the short QT interval differentiate it from ischemia.  

It is important to remember that even a patient with a normal variant could have a myocardial infarction, just as patients with completely normal ECGs may have MI.  

It is only to say that the ischemia is not represented on this ECG.

See this post on Benign T-wave Inversion.

Here is a relevant post on the inverted T-waves of Persistent Juvenile T-wave Pattern with many other the normal variants of T-wave inversion.

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