Saturday, April 8, 2017

8 year-old with report of "syncope and an abnormal ECG".

This case was contributed by John Dunbar, an outstanding Hennepin EM Resident.

A previously healthy, fully immunized 8 year-old African American boy presented with a report of "syncope and abnormal ECG" by EMS.  

On arrival to the ED, he was awake but lethargic with EMS report of normal prehospital glucose by EMS, HR in the 90s and BP's in the 110s/70s and O2 sats of at least 98% on room air.  Immediately, a bedside cardiac ultrasound was performed while the ECG was being setup and this showed good global function, no effusion, no overt ventricular enlargement or septal hypertrophy (measurements not taken) and a normal caliber IVC without B-lines bilaterally.  A 12-lead ECG was performed as below and looked similar to the prehospital ECG (not available): 
Figure 1.
Sinus rhythm with normal axis.
Biphasic T-waves with asymmetric T-wave inversion in V1-V4
ST elevation in V1, V2, V3.
Unusual T-wave inversion in V2 and V3

The ECG was texted to Dr. Smith contemporaneously with the patient's ED evaluation and this is what Smith wrote:"Is he African American?  This is a different kind of normal variant.  This is not a case of classic juvenile T-waves.  Check out the following blog post which shows some other normal variants, of which this is one: Persistent Juvenile T-wave Pattern. This post has examples of various benign T-wave patterns."

Normal variants T-wave inversion includes, but is not limited to:
1.  ST-T Normal Variation (STTNV) 
2. "Persistent" Juvenile T-waves 
      --As they're not really "persistent," it is more appropriately called Juvenile T-W Pattern (JTWP) because this T-wave pattern is normal for the very young and up until adolescence, but it is not necessarily persistent, in that it may come and go.
3.  Benign T-wave Inversion (BTWI), which is often lumped together with STTNV (1).  

I like to differentiate BTWI from STTNV.  BTWI, which Dr. Smith first learned about in Chou's textbook "Electrocardiography in Clinical Practice," has STE and T-wave inversion primarily in V3-V6; STTNV primarily in V2 and V3. 

The pattern in this 8 yo is consistent with ST-T Normal Variation (STTNV), also called “ST Elevation and Inverted T Wave.”  It is a normal variant of early repolarization that can persist just like Juvenile T-wave Pattern (JTWP).
Here are two examples of STTNV from the earlier post which was written largely by Brooks Walsh (

Choo 2002 (2)
T-wave inversion is mostly in V2 and V3
Figure 2.

2009 Papadakis (3)
Again, mostly in V2 and V3
Figure 3.

1. The ST elevation in V1-V3 with the asymmetric t-wave inversions is what makes this STTNV. This pattern is less commonly seen in children. Some consider it a variant of JTWP, though others feel it is a separate entity (1).  This pattern is subtly different from Benign T-Wave Inversion, which is primarily in V3-V6 (see 3 examples below) and this post: Benign T-wave Inversion: view video or read text

2. Juvenile T-wave pattern (JTWP) does have asymmetric inverted T-waves in V1-V3, as in this normal ECG from a 3 year old, borrowed from Chan et al. (10).  These T-wave inversions can extend to V4.
Juvenile T-wave Pattern
Figure 4: ECG of 3 year-old girl showing characteristics of JTWP:
Shallow T-wave inversions, limited to V1-V3, V4
Assymetric morphology of the inverted T-wave
No significant ST Elevation

Here is are 3 examples of Benign T-wave Inversion:
Notice the precordial T-wave Inversion is primarily in V3-V6.  There is typical STE of early repol in V2.  There is a small S-wave and large R-wave in V4.  Often there is also T-wave inversion in inferior leads.


JTWP, BTWP, and STTNV can persist into adulthood and complicate presentations for chest pain, syncope, palpitations, SOB, etc. as these patterns have to be differentiated from ACS, PE, ARVD, etc.

- PJTWP typically resolves by age 19 in males and age 30 in women and is more common in women (4, 5, 6, 7, 8, 9)  

- BTWI is more common in African American males and athletes. (1).

Dr. K. Wang has shown that STTNV (which Smith calls BTWI, as the ECGs in this cohort all had T-wave inversion in V3-V6) is by far most common in African American males.   Smith has studied all the EKGs in his cohort and found that:

1. There is a relatively short QT interval (QTc less than 425ms).  
2. The leads with T-wave inversion often have very distinct J-waves.
3. The T-wave inversion is usually in leads V3-V6 (in contrast to Wellens' syndrome, in which they are V2-V4)
4. The T-wave inversion does not evolve and is generally stable over time (in contrast to Wellens', which evolves). 
5. The leads with T-wave inversion (left precordial) usually have some ST elevation 
6. Right precordial leads often have ST elevation typical of classic early repolarization 
7. The T-wave inversion in leads V4-V6 is preceded by minimal S-waves 
8. The T-wave inversion in leads V4-V6 is preceded by high R-wave amplitude 
9. II, III, and aVF also frequently have T-wave inversion.

Case Continued

With respect to this specific case, the history was more consistent with a seizure: while at the store, he reported to his mother he didn't feel well with a mild frontal headache. He then collapsed and was noted by an EMT bystander to have eye deviation, rhythmic tongue movements and increased tonic activity.  When EMS arrived 6 minutes later, he remained confused with his eyes open unable to follow commands more consistent with postictal state than syncope. On arrival to the ED he was drowsy with a non-focal exam and persistence of his mild headache that resolved over 30 minutes or so. He had no prodromal symptoms other than headache, no antecedent illness and no fevers.

However, given the perceived ECG abnormalities, Peds Cardiology was asked to review the ECG and reported it was normal but did not expand.  When sent to Dr. Smith, he immediately recognized the T-wave inversions are a normal variant similar to STTNV.  This has been reviewed in the blog before and you can explore the prior posts ( for more details.  Differentiating pathologic findings from normal variants among both adult and pediatric ECGs is paramount both for rapid diagnosis and prevention of therapeutic delay on the one hand, and avoiding excessive downstream testing on the other. 

After normal labs and period of observation patient was discharged with close follow up with pediatric neurology and diagnosis of first time seizure.  

(1) Roukoz H.  Wang K.  ST Elevation and Inverted T Wave as Another Normal Variant Mimicking Acute Myocardial Infarction: The Prevalence, Age, Gender, and Racial Distribution.  Annals of Noninvasive Electrocardiology 16(1):64-69, January 2011.   doi:10.1111/j.1542-474X.2010.00410.x.
This is Benign T-wave Inversion

(2) Choo JK, Abernethy III WB, Hutter Jr. AM. Electrocardiographic observations in professional football players. Am. J. Cardiol.2002;90(2):198-200. doi:10.1016/S0002-9149(02)02454-2.

(3) Papadakis M, Basavarajaiah S, Rawlins J, et al. Prevalence and significance of T-wave inversions in predominantly Caucasian adolescent athletes. Eur. Heart J. 2009;30(14):1728-1735. doi:10.1093/eurheartj/ehp164.

(4)  Marcus FI.  Prevalence of T-Wave Inversion Beyond V1 in Young Normal Individuals and Usefulness for the Diagnosis of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia.  Am J Cardiol 2005;95:1070-1071.

(5) Kaid KA, Maqsood A, Cohen M, Rothfeld E. Further characterization of the “persistent juvenile T-wave pattern” in adults. J. Electrocardiol. 2008;41(6):644-645. doi:10.1016/j.jelectrocard.2008.08.028.

(6) Aro AL, Anttonen O, Tikkanen JT, et al. Prevalence and Prognostic Significance of T-Wave Inversions in Right Precordial Leads of a 12-Lead Electrocardiogram in the Middle-Aged Subjects. Circulation 2012;125(21):2572-2577. doi:10.1161/CIRCULATIONAHA.112.098681.

(7) Assali A-R, Khamaysi N, Birnbaum Y. Juvenile ECG pattern in adult black arabs. J. Electrocardiol. 1997;30(2):87-90. doi:10.1016/S0022-0736(97)80014-3.

(8) Malhotra A, Dhutia H, Gati S, et al. 103 Prevalence and significance of anterior T wave inversion in females. Heart Br. Card. Soc.2014;100 Suppl 3:A60. doi:10.1136/heartjnl-2014-306118.103.

(9).  Rawlins J, Carre F, Kervio G, et al. Ethnic Differences in Physiological Cardiac Adaptation to Intense Physical Exercise in Highly Trained Female Athletes. Circulation 2010;121(9):1078-1085. doi:10.1161/CIRCULATIONAHA.109.917211.

(10).  Chan TC, Sharieff GQ, Brady WJ. Electrocardiographic Manifestations: Pediatric ECG. J. Emerg. Med. 2008;35(4):421-430. doi:10.1016/j.jemermed.2007.09.039.


  1. Nice analysis and ECG, again. At first place, given the history, I was worry about RV arythmogenic cardiopathy (whitout epsilon waves), apart of the benign patterns. Can you comment on how this can be excluded whitout formal echo? Thanks!

    1. Alain,
      In this case the morphology is classic normal variant and you don't have to worry.
      I suppose if the historical details of the syncope are particularly worrisome, then further investigation is warranted.
      My understanding is that echo will not diagnose ARVD. MRI is required.

    2. There is A LOT of voltage in V2 so ARVD is very unlikely

  2. Again serials to the rescue,plus he,if it's changing in front of you, something's acutely up,if not, chronic

    1. That is true, but this case is a classic normal variant morphology. Serial ECGs not necessary for someone who recognizes it.

  3. Hello Dr. Smith,
    I was reading 2017 ESC guideline: ''International recommendations for electrocardiographic interpretation in athletes'' and found a new term ''black athlete repolarization variant'', which was described as: ''J-point elevation and convex (‘domed’) ST segment elevation followed by T wave inversion in leads V1-V4 in black athletes''.
    I was confused. Is that resembles '' STTNV'' as you decribed above, or ''BTWI''? I also found another study (European Heart Journal (2011) 32, 2304–2313) said that '' black athlete repolarization variant'' prone to present TWI in V1-4 (12.7%) but not lateral leads (4.1%). In fact, as the article said, this characteristic distinguish this variant from hypertrophic cardiomyopathy, which is another important differential Dx. Thank you very much!

  4. Allen,
    Both of those are STTNV.
    BTWI is another normal variant, as seen in the bottom 3 ECGs.
    Steve Smith


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