A young man with a 'pathologic' ECG

Written by Magnus Nossen

The patient in today's case is a young adult male who has had annual cardiological follow-ups due to a pathological ECG. His previous studies include annual Holter monitoring for palpitations and biennial echocardiograms. The Holter recordings and echocardiograms were unremarkable.

The patient contacted EMS for chest pain and had the following ECG recorded. He described the chest pain as dull and rated the pain 7/10. He had no risk factors for CAD. How would you manage this patient?

Figure-1 = ECG #1.

Smith:

You might find the 3 x 4 format to be easier to read than 6 x 2.  I do, so I re-formatted the ECG (though I did a bad job of it). 

What do you think?

The patient was accepted for emergent coronary angiography due to chest pain and ST-elevation. On arrival he was well appearing but endorsed ongoing chest discomfort. Repeat ECG was unchanged. The coronary angiogram did not reveal any pathologic changes. Another ECG recorded after coronary angiography was unchanged from the initial tracing. High sensitivity troponin T following the angiogram returned 11ng/L. Repeat troponin 4 hours later was 16ng/L. (Ref value < 15ng/L).

Based on the patient's initial ECG, his report of ongoing chest pain and one troponin T value above normal reference value — the patient was diagnosed with acute pericarditis. He was placed on 3 months of colchicine — and told to  refrain from hard physical work and exercise. 

    — Do you agree with the diagnosis and treatment? —

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Discussion: The ECG in Figure-1 does not represent pericarditis. Instead, this ECG shows typical findings of early repolarization, with benign T wave inversion in lead V4. BTWI (Benign T Wave Inversion) has been featured regularly on Dr. Smith's ECG Blog. Patients with this ECG pattern are likely to be young, male and of African heritage (which today's patient was). Usually BTWI is associated with a relatively short QTc interval — and, with a number of leads showing T wave inversion, some of which manifest STE and distinct J waves. The ECG in BTWI often shows high amplitude R waves in leads with STE or TWI. See this post for many examples of BTWI.

Following the angiogram, the patient was transferred to the regional hospital where a cardiac MRi was ordered due to suspicion of pericardial disease. The MRi was not done immediately and while waiting for this imaging study, high sensitivity troponin I  was below the limit of detection x3. Inflammatory markers and CBC were normal. The patient had to wait a number of days for the MRi to be scheduled (which reduced reliability of the normal result). 

Despite this normal MRi — the discharge diagnosis was still acute (myo) pericarditis (!). I suspect the discharge diagnosis was hinged on a single elevated troponin T and misinterpretation of the ECG as being consistent with pericarditis. The barely elevated troponin T in this case is very likely related to the angiography procedure itself and not due to any pathological condition. It is important to remember that diagnostic angiography can give rise to minimal troponin release (1,2)   

I have chosen to present this case for several reasons. This case illustrates well the importance of recognizing benign ECG patterns. This patient had several follow-up visits and tests that were completely unnecessary. The follow-up and repeated examinations may have a detrimental effect on the patient's psyche. 

For this patient even an angiogram was done. Although diagnostic angiography is generally a safe procedure, it is not completely without risk of complications. Colchicine is for patients with normal renal function at therapeutic doses rather safe. GI side effects with nausea, vomitting and diarrhea are quite common.  Colchicine however is a drug with a narrow therapeutic index. This means the potential for overdose or toxic effect needs to be remembered. In toxic concentrations colchicine can have serious side effect and may lead to bone marrow suppression, which can be life threatening. If you want to prescribe a drug with this potential side effect, you have to be sure the diagnosis is correct. 

Sometimes doctors are biased. We are focused on "making the diagnosis". Throughout medical school and medical training, we focus on recognizing conditions that have a negative impact on morbidity and mortality. Diagnosing benign conditions is less "rewarding". I think this is why we do not remember findings associated with benign conditions as easily as we we do findings with more prognostic significance. We need to remember that sometimes diagnosing a benign condition like BTWI can be very important, both in terms of avoiding unnecessary use of resources and in terms of preventing patients from undergoing potentially harmful diagnostic tests and treatments that they do not need. Below is a summary of key ECG findings seen in BTWI. 

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BTWI: is a normal variant associated with early repolarization.  K. Wang studied it.  He reviewed ECGs from all 11,424 patients who had at least one recorded during 2007 at Hennepin County Medical Center (where Dr. Smith works) and set aside the 101 cases of benign T-wave inversion.  97 were African American (black).  3.7% of African American men and 1% of Black women had this finding.  1 of 5099 white patients had it.  Aside from an 8.8% incidence (9 of 109) black males aged 17-19, it was evenly distributed by age group.

Dr. Smith reviewed these 101 ECGs, and described the key findings of the pattern:

1. There is a relatively short QT interval (QTc < 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 (contrast Wellens, in which they are V2-V4)

4. The T-wave inversion does not evolve and is generally stable over time 

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. 

Follow up: This patient was asked to return for an outpatient follow up where it was emphasized to him that his ECG represents a normal variant. He was reassured that his Echo and Holter findings were completely normal — and that there was no need for further follow up. Colchicine was discontinued.

This patient did not need an angiogram. The Queen of Hearts AI model significantly reduces false positve cath lab activations. The AI-model is not concerned about the ECG in todays case. There is no concern for ischemia and the LVEF model predicts a normal left ventricular ejection fraction. 

Figure-2 = QoH Interpretation.

Learning points: 

• BTWI can mimic ischemia and pericarditis to the untrained interpreter.
• Making a diagnosis of a benign condition is very important, and leads to better patient management.
• High sensitivity troponin may increase slightly following coronary angiogram.
  
  
  

Smith: 

I am reminded of this case written by Pendell when he was a med student in 2013.  He recognized normal variant ST Elevation, while no one else did.  They diagnosed pericarditis because of the STE and thus almost missed a pulmonary embolism.  

31 Year Old Male with RUQ Pain and a History of Pericarditis. Submitted by a Med Student, with Great Commentary on Bias!

There are over 20 Examples of "Benign T-wave Inversion" at this post.  It is really worthwhile to look at many examples:

Understanding this pathognomonic ECG would have greatly benefitted the patient.

References:

1) Coronary angiography-related myocardial injury as detected by high-sensitivity cardiac troponin T assay - PubMed

2) Subtle myocardial damage associated with diagnostic coronary angiography alone - PubMed

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MY Comment, by KEN GRAUER, MD (5/15/2025):

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Today's case by Dr. Nossen illustrates "the righting of a wrong".

• The young adult male whose ECG is the subject of today's post was apparently being followed by cardiology for "a pathologic ECG".
• We do not know many of the details of this case — especially including how the designation was made that this patient's baseline ECG was "pathologic". That said — we do know that serial Echocardiograms have been unremarkable, and Holter monitoring has not revealed any significant arrhythmia.
• As best we can tell — this patient is otherwise healthy (without hypertension or other medical condition). And now we are introduced to today's case — as we are told of the patients new episode of CP (Chest Pain), rated 7/10 in severity and worrisome enough to this patient that he called EMS.

We are asked to assess this patient's initial ECG — that I've reproduced and labeled in Figure-3. No prior ECG is available for comparison.

• Dr. Nossen highlights in his discussion reasons why despite the protocol prescribed to this patient of yearly cardiology visits with serial testing — his ECG looks benign! I focus my comment on highlighting those ECG findings noted above by Dr. Nossen as characteristic of BTWI (Benign T Wave Inversion), based on Dr. Smith's review in the March 22, 2022 post.

The purpose of my comment — is that recognition of this patient's ECG as almost certainly benign can (and should) be made within seconds!

• As shown in Figure-3 — The rhythm is sinus (perhaps with some sinus arrhythmia). The QTc interval is relatively short (under 400 msec.).
• QRS amplitude is diffusely increased.
• Leads V3 and V4 especially caught "my eye". RED arrows hightlight prominent J-point notching in these 2 leads that manifest upward sloping (ie, "smiley"-configuration) ST elevation — with the T wave inversion (BLUE arrow) in lead V4 being seen in this left-sided lead that also manifests ST elevation. It is the shape of the QRST complex in these 2 leads — in association with markedly increase voltage in so many leads on this tracing that "jumps out" as looking benign.
• More subtle J-point notching is also seen in other leads (RED arrows in leads V5,V6).

NOTE: Even though I instantly recognized the ECG in Figure-1 as almost certain to represent a benign BTWI pattern — this patient did develop new CP severe enough to prompt him to call EMS. Given this clinical scenario — such patients may need sufficient evaluation in the ED (ie, at least 2 serum Troponins, at least 2 serial ECGs, close oversight) — until a level of greater comfort is reached in ruling out an acute cardiac event. (Cardiac cath does not necessarily need to be done in all such cases).

• P.S.: If this was my patient — I would make a reduced size copy of his baseline ECG for him to carry in his wallet, so that if ever again he presents for emergency evaluation — a baseline ECG will be readily available for comparison.

Figure-3: I have labeled the initial ECG in today's case.

Um