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HOME ABOUT EXAMS FOAMED EDUCATION RESOURCES ECG LIBRARY REVIEWS JULY 14, 2013
T Wave
The T wave is the positive deflection after each QRS complex.
T Wave Abnormalities
Hyperacute T waves
Inverted T waves
Biphasic T waves
Camel Hump T waves
Flattened T waves
Peaked T Waves
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Hyperacute T Waves
Broad, asymmetrically peaked or hyperacute T-waves are seen in the early stages of ST-elevation MI (STEMI) and often precede
the appearance of ST elevation and Q waves. They are also seen with Prinzmetal angina.
Loss of precordial T-wave imbalance occurs when the upright T wave is larger than that in V6. This is a type of hyperacute T wave.
The normal T wave in V1 is inverted. An upright T wave in V1 is considered abnormal especially if it is tall (TTV1), and
especially if it is new (NTTV1).
This finding indicates a high likelihood of coronary artery disease, and when new implies acute ischemia.
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Inverted T Waves
Hypertrophic cardiomyopathy
Raised intracranial pressure
T wave inversion in lead III is a normal variant. New T-wave inversion (compared with prior ECGs) is always abnormal. Pathological T wave
inversion is usually symmetrical and deep (>3mm).
Paediatric T Waves
Inverted T-waves in the right precordial leads (V1-3) are a normal finding in children, representing the dominance of right
ventricular forces.
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T-wave inversions in the right precordial leads may persist into adulthood and are most commonly seen in young Afro-
Caribbean women. Persistent juvenile T-waves are asymmetric, shallow (<3mm) and usually limited to leads V1-3.
T-wave inversions due to myocardial ischaemia or infarction occur in contiguous leads based on the anatomical location of the area of
ischaemia/infarction:
Anterior = V2-6
NOTE:
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Fixed T-wave inversions are seen following infarction, usually in association with pathological Q waves.
Infe rior T wave inve rsion with Q wave s due to prior infe rior MI
T wave inve rsion in the late ral le ads due to acute ischae mia
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Ante rior T wave inve rsion with Q wave s due to re ce nt ante rior MI
Left bundle branch block produces T-wave inversion in the lateral leads I, aVL and V5-6.
Right bundle branch block produces T-wave inversion in the right precordial leads V1-3.
T-wave inve rsion in the right pre cordial le ads due to RBBB
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Ventricular Hypertrophy
Left ventricular hypertrophy produces T-wave inversion in the lateral leads I, aVL, V5-6 (left ventricular strain pattern), with a
similar morphology to that seen in LBBB.
Right ventricular hypertrophy produces T-wave inversion in the right precordial leads V1-3 (right ventricular strain pattern)
and also the inferior leads (II, III, aVF).
T wave inve rsion in the infe rior and right pre cordial le ads due to RVH
Pulmonary Embolism
Acute right heart strain (e.g. secondary to massive pulmonary embolism) produces a similar pattern to RVH, with T-wave
inversions in the right precordial (V1-3) and inferior (II, III, aVF) leads.
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T wave inve rsion in the infe rior and right pre cordial le ads in a patie nt with bilate ral PEs
Pulmonary embolism may also produce T-wave inversion in lead III as part of the SI QIII TIII pattern (S wave in lead I, Q wave in
HOCM is associated with deep T wave inversions in all the precordial leads.
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Events causing a sudden rise in ICP (e.g. subarachnoid haemorrhage) produce widespread deep T-wave inversions with a bizarre
morphology.
Biphasic T Waves
Myocardial ischaemia
Hypokalaemia
Ischaemia
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Hypokalaemia
Wellens Syndrome
Wellens syndrome is a pattern of inverted or biphasic T waves in V2-3 (in patients presenting with ischaemic chest pain) that is highly
specific for critical stenosis of the left anterior descending artery.
Type 2 Wellens T-waves are biphasic, with the initial deflection positive and the terminal deflection negative
Wellens Type 1
Wellens Type 2
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This is a term used by the great ECG lecturer and Emergency Physician Amal Mattu to describe T-waves that have a double peak or camel
hump appearance.
Prominent U w aves fused to the end of the T wave, as seen in severe hypokalaemia
Hidden P w aves embedded in the T wave, as seen in sinus tachycardia and various types of heart block
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Flattened T Waves
Flattened T waves are a non-specific finding, but may represent ischaemia (if dynamic or in contiguous leads) or electrolyte
abnormality, e.g. hypokalaemia (if generalised).
Ischaemia
Dynamic T-wave flattening due to anterior ischaemia (above). T waves return to normal once the ischaemia resolves (below).
Hypokalaemia
Note generalised T-wave flattening with prominent U waves in the anterior leads (V2 and V3).
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Related Topics
P wave
Q wave
R wave
Further Reading
ECG CLINICAL CASES Your favourite ECGs placed in clinical context with a challenging Q&A approach
ECG and Cardiology Eponymous Syndromes Cheats guide to eponymous emancipation
ECG Exam Template a framework for the FACEM part 2 exam.
Author Credits
Words - Ed Burns
Pictures - Ed Burns
Web Editing - Ed Burns
References
Surawicz B, Knilans TK. Chous Electrocardiography in Clinical Practice. 6th Edition. Saunders Elsevier 2008.
Wagner, GS. Marriotts Practical Electrocardiography (11th edition), Lippincott Williams & Wilkins 2007.
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