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T Wave

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1. Do patients with LBBB and STEMI, when reperfused, develop T-wave inversion (reperfusion T-waves)?

Do patients with LBBB and STEMI, when reperfused, develop T-wave inversion (reperfusion T-waves)? Dr. Smith's ECG Blog: Do patients with LBBB and STEMI, when reperfused, develop T-wave inversion (reperfusion T-waves)? Friday, January 20, 2017 The case below was contributed by Pendell Meyers, an EM G1 at Mt. Sinai (the case did not come from Mt. Sinai though!) Pendell is the lead author on our . Meyers HP. Limkakeng AT. Jaffa EJ. Patel A. Theiling BJ. Rezaie SR. Stewart T. Zhuang C. Pera VK (...) . Smith SW . Validation of the Modified Sgarbossa Rule for Diagnosis of STEMI in the Presence of Left Bundle Branch Block. American Heart Journal 170(6):1255-1264; December 2015. Before the case, a few comments: Pendell and I just published a case report of a patient with left bundle branch block who presented with chest pain that then resolved. His ED ECG showed his baseline LBBB, with no evidence of MI. Over the ensuing hours, he developed classic T-wave inversion of Wellens' syndrome

2017 Dr Smith's ECG Blog

2. Twenty-Four-Hour Measures of Heart Rate-Corrected QT Interval, Peak-to-End of the T-Wave, and Peak-to-End of the T-Wave/Corrected QT Interval Ratio During Antipsychotic Treatment. (PubMed)

Twenty-Four-Hour Measures of Heart Rate-Corrected QT Interval, Peak-to-End of the T-Wave, and Peak-to-End of the T-Wave/Corrected QT Interval Ratio During Antipsychotic Treatment. Prolonged ventricular repolarization, measured by heart rate-corrected QT interval (QTc) prolongation, might be a biomarker for risk of torsade de pointes (TdP) and sudden cardiac death. However, the predictive value of QTc has been challenged, and a component of QTc, peak-to-end of the T-wave (Tpe), and a high Tpe/QT

2019 Journal of Clinical Psychopharmacology

3. Just as hyperacute T-waves can be reciprocal to T-wave inversion (last case),.....

Just as hyperacute T-waves can be reciprocal to T-wave inversion (last case),..... Dr. Smith's ECG Blog: Just as hyperacute T-waves can be reciprocal to T-wave inversion (last case), Sunday, June 12, 2016 ( ), T-wave inversion can be reciprocal to STEMI of opposite wall! This case was sent by Arthur Lee. Case : A 50 yr old woman presented after a syncopal episode, with sweating and left arm numbness. There was no chest pain or SOB, at least none reported by Dr. Lee. Here is her presenting ECG (...) : Arthur asked: "How do we interpret the anterior T-wave inversion? Are they reperfusion T-waves of the anterior wall?" What do you think? Answer : There is very abnormal T-wave inversion in aVL which is typical of subtle transmural/subepicardial (due to occlusion) ischemia to the inferior wall. This is reciprocal T-wave inversion. The high lateral wall is reciprocal to the inferior wall. Similarly, the precordial T-wave inversions in V2-V4 are reciprocal to posterior wall transmural/subepicardial (due

2016 Dr Smith's ECG Blog

4. Two cases texted to me for concern of inferior hyperacute T waves and a flipped T in aVL - do either, neither, or both need emergent reperfusion?

Two cases texted to me for concern of inferior hyperacute T waves and a flipped T in aVL - do either, neither, or both need emergent reperfusion? Dr. Smith's ECG Blog: Two cases texted to me for concern of inferior hyperacute T waves and a flipped T in aVL - do either, neither, or both need emergent reperfusion? Monday, November 12, 2018 Written by Pendell Meyers I received two texts recently, in both cases the practitioners were worried about possible inferior hyperacute T-waves (...) with an inverted T-wave in aVL. I was not given any clinical history. What would you tell the team in these two cases? Case 1 Case 2 My responses: Case 1: "Not hyperacute. The T-wave in aVL is likely that way at baseline, send baseline if available. What's the story?" Case 2: "Agree with concern for inferior posterior. This is almost completely diagnostic barring an identical baseline. What's the story?" Did you agree with my assessments? Why do I say that Case 1 is not hyperacute and Case 2 is? Was I even

2018 Dr Smith's ECG Blog

5. de Winter's T-waves evolve into Wellens' waves

de Winter's T-waves evolve into Wellens' waves Dr. Smith's ECG Blog: de Winter's T-waves evolve into Wellens' waves Monday, June 19, 2017 This comes from a paramedic in Hungary named Farkas László: This patient had chest pain that then resolved: There is diffuse ST depression, with ST Elevation in aVR and a hyperacute T-wave in lead V3 V3 is likely a de Winter's T-wave (ST depression with large upright T-wave) Since this T-wave is not obviously massive, one might think this is a posterior MI (...) (right precordial ST depression) or simply diffuse subendocardial ischemia (diffuse ST depression with STE in aVR). 11 minutes later, the chest pain was gone, suggesting spontaneous reperfusion (autolysis of thrombus). This ECG was recorded: All ST depression in V3 is gone Only residual ST depression remains The T-waves in V2 and V3 are smaller This rules out posterior MI: as an artery reperfuses in posterior MI, the T-wave gets larger! (Posterior reperfusion T-waves) See posterior reperfusion T

2017 Dr Smith's ECG Blog

6. ST Depression and T-wave inversion in V2 and V3.

ST Depression and T-wave inversion in V2 and V3. Dr. Smith's ECG Blog: ST Depression and T-wave inversion in V2 and V3. Tuesday, February 12, 2019 A middle aged male dialysis patient was found disorganized and paranoid. He had no chest pain or dyspnea. An ECG was recorded. The clinician was worried about his ECG and showed it to me: What do you think? When I saw this ECG, I immediately recognized right ventricular hypertrophy as the cause of the ST depression and T-wave inversion in leads V2 (...) and V3. In other words, I was certain that this was a chronic finding on the ECG. The worried clinician stated there are no old ECGs to compare with, and no records. I remained certain that this was RVH as the findings are classic: Large R-wave in V1, large S-wave in lead I, and typical right precordial ST-T that mimic posterior STEMI. If the QRS were normal, and the patient had chest pain, I would have said this was posterior MI, or possibly hypokalemia (see this post: ). Later, however, we found

2019 Dr Smith's ECG Blog

7. 15 yo AAM with ST Elevation and T-wave Inversion. Hypertrophic Cardiomyopathy or Normal ("Variant")?

15 yo AAM with ST Elevation and T-wave Inversion. Hypertrophic Cardiomyopathy or Normal ("Variant")? Dr. Smith's ECG Blog: 15 yo AAM with ST Elevation and T-wave Inversion. Hypertrophic Cardiomyopathy or Normal ("Variant")? Wednesday, January 2, 2019 Is this normal or hypertrophic cardiomyopathy (HOCM)? The mother of a 15 yo African American male brought her son to the clinic for a sports physical. There was a family history of sudden death. The clinic recorded this ECG and was alarmed: Should (...) him and recorded this ECG, which is slightly different but within normal day to day variation: There is also "Sinus arrhythmia" (varying sinus rate) V4 is classic benign "variant" and is the most recognizable lead in this ECG morphology. This has been called "Benign T-wave Inversion" BTWI) in this blog, as Chou named it in his textbook. BTWI is a normal variant associated with early repolarization. He reviewed ECGs from all 11,424 patients who had at least one recorded during 2007 at and set aside

2019 Dr Smith's ECG Blog

8. Large T-waves and a Computer Interpretation of ***Acute MI***

Large T-waves and a Computer Interpretation of ***Acute MI*** Dr. Smith's ECG Blog: Large T-waves and a Computer Interpretation of ***Acute MI*** Saturday, November 24, 2018 This ECG was texted to me with no information: I answered: "Show me the whole 12-lead." Here it is: Computer Interpretation: SINUS RHYTHM INFERIOR MYOCARDIAL INFARCTION, POSSIBLY ACUTE ST ELEVATION, CONSIDER ANTERIOR INJURY [MARKED ST ELEVATION W/O NORMALLY INFLECTED T WAVE IN V2-V5] ***ACUTE MI*** What do you think (...) ? This was my answer, in which I suspected that he was worried about possible hyperacute T-waves: "I suspect these do not represent hyperacute T waves. Although the T-waves tower over the R-waves, they have extreme upward concavity. Although MI can easily have upward concavity, it is not usually this pronounced. If it is a chest pain patient, I would get a formal echo and serial ECGs. And look for an old EKG." They found this old one scanned into the chart from a stress test. There were no others: Notice

2019 Dr Smith's ECG Blog

9. Anterior STEMI Evolves to de Winter's T-waves

Anterior STEMI Evolves to de Winter's T-waves Dr. Smith's ECG Blog: Anterior STEMI Evolves to de Winter's T-waves Saturday, January 19, 2019 A middle-aged man called EMS for chest pain. This prehospital ECG was recorded: Obvious Anterior STEMI due to proximal LAD occlusion (with STE in aVL and reciprocal STD in inferior leads). On arrival to the ED, this ECG was recorded 10 minutes later: Almost all STE is gone, but the hyperacute T-waves remain While waiting for the cath team (...) , this was recorded 30 minutes after 2nd ECG: Now there are classic de Winter's T-waves. This shows the dynamic nature of coronary thrombus. Presumably, the thrombus had autolysis to a very small degree, allowing a trickle of blood flow through the LAD, enough to eliminate the ST elevation. The patient was found to have a 100% proximal LAD occlusion. By the time of the angiogram, which is never at the same the time as the ECG, there was not even a trickle of blood. See this related post, with discussion of de

2019 Dr Smith's ECG Blog

10. Dynamic, Reversible, Ischemic T-wave inversion mimics Wellens'. All trops negative.

Dynamic, Reversible, Ischemic T-wave inversion mimics Wellens'. All trops negative. Dr. Smith's ECG Blog: Dynamic, Reversible, Ischemic T-wave inversion mimics Wellens'. All trops negative. Friday, December 14, 2018 A middle-aged man presented with 7-8/10 non-radiating chest tightness to the left chest wall, associated with nausea but no diaphoresis, that began while walking approximately 40 minutes prior to arrival at the ED. The pain resolved as he arrived to the emergency department. He had (...) , Pattern A, with terminal T-wave inversion in V2-V4, preserved R-waves, and it appears to be Wellens' syndrome, as it occurred after resolution of typical angina pain. We assumed this was Wellens' syndrome and treated as such. Wellens' syndrome represents the aftermath of an unrecorded occlusion (STEMI) with spontaneous reperfusion. Wellens' waves are "reperfusion T-waves" and are identical to the T-waves seen after therapeutic reperfusion. If true Wellens', they always are associated with slightly

2019 Dr Smith's ECG Blog

11. Among patients with left bundle branch block, T-wave peak to T-wave end time is prolonged in the presence of acute coronary occlusion. (PubMed)

Among patients with left bundle branch block, T-wave peak to T-wave end time is prolonged in the presence of acute coronary occlusion. Assessing the effect of myocardial ischemia on ventricular repolarization in the setting of left bundle branch block (LBBB) poses a challenge due to secondary prolongation of the QT interval inherent in LBBB. The T-wave peak to T-wave end (TpTe) interval has been noted to prolong during myocardial ischemia and correct after reperfusion in patients with normal

2017 International journal of cardiology

12. Frequency of Inverted Electrocardiographic T Waves (Cerebral T Waves) in Patients With Acute Strokes and Their Relation to Left Ventricular Wall Motion Abnormalities. (PubMed)

Frequency of Inverted Electrocardiographic T Waves (Cerebral T Waves) in Patients With Acute Strokes and Their Relation to Left Ventricular Wall Motion Abnormalities. Transient, symmetric, and deep inverted electrocardiogram (ECG) T waves in the setting of stroke, commonly referred to as cerebral T waves, are rare, and the underlying mechanism is unclear. Our study aimed to test the hypothesis that cerebral T waves are associated with transient cardiac dysfunction. This retrospective study (...) included 800 patients admitted with the primary diagnosis of hemorrhagic or ischemic stroke. ECGs were examined for cerebral T waves, defined as T-wave inversion of ≥5 mm depth in ≥4 contiguous precordial leads. Echocardiograms of those meeting these criteria were examined for the presence of left ventricular (LV) wall motion abnormalities. Follow-up evaluation included both ECG and echocardiogram. Of the 800 patients, 17 had cerebral T waves on ECG (2.1%). All 17 patients had ischemic strokes

2017 American Journal of Cardiology

13. Does manual T-wave window adjustment affect microvolt T-wave alternans results in patients with structural heart disease?

Does manual T-wave window adjustment affect microvolt T-wave alternans results in patients with structural heart disease? Microvolt T-wave alternans (MTWA) analysis can identify patients at low risk of sudden cardiac death who might not benefit from an implantable cardioverter-defibrillator (ICD). Current spectral methodology for performing MTWA analysis may "miss" part of the T-wave in patients with QT prolongation. The value of T-wave window adjustment in patients with structural heart (...) disease has not been studied.We assembled MTWA data from 5 prior prospective studies including 170 patients with reduced left ventricular ejection fraction, adjusted the T-wave window to include the entire T-wave, and reanalyzed MTWA.Of 170 patients, 43% required T-wave window adjustment. Only 3 of 170 patients (1.8%) had a clinically significant change in MTWA results.In 98.2% of patients, T-wave window adjustment did not improve the accuracy of MTWA analysis. Spectral MTWA as currently implemented

2017 Journal of electrocardiology

14. T Wave Safety Margin during the Process of ICD Implantation As a Novel Predictor of T Wave Oversensing (PubMed)

T Wave Safety Margin during the Process of ICD Implantation As a Novel Predictor of T Wave Oversensing Introduction: T wave oversensing (TWOS) is a major drawback of implantable cardioverter defibrillator (ICD) and data on predictors of TWOS in ICD is limited. We aimed to calculate a novel index of T wave safety margin (TWSM) and assess its potential for evaluating TWOS during the procedure of ICD implantation. Methods and Results: Thirty-two consecutive patients with ICD implantation were (...) enrolled. During each procedure of ICD implantation, different ICD generators were connected to implanted sensing lead through active-fixation leads and bridging cables. R and T wave amplitudes were measured on ICD printouts according to the gain. The ICDs were programed to the most sensitive settings to reveal possible TWOS. A novel index TWSM was calculated according to the corresponding sensing algorithm of ICD. There was discrepancy of R wave amplitudes measured by different ICDs (P < 0.01

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2017 Frontiers in physiology

15. Is this ECG diagnostic of coronary occlusion? Also: Inferior de Winter's T-waves on prehospital ECG??

Is this ECG diagnostic of coronary occlusion? Also: Inferior de Winter's T-waves on prehospital ECG?? Dr. Smith's ECG Blog: Is this ECG diagnostic of coronary occlusion? Also: Inferior de Winter's T-waves on prehospital ECG?? Sunday, January 28, 2018 This post was written by one of who is an ECG whiz, Daniel Lee. A man is his late 50’s presents to the ED with 1 hour of post exertional chest pressure associated with diaphoresis and nausea. He has a history of known CAD, diabetes (...) in aVL less than 1mm along with new T-wave inversion . Leads II, III, aVF show about 0.5 mm ST elevation that is new compared to the previous ECG. Furthermore there is a new positive T wave in lead III . Subtle changes, but with the history is very nearly diagnostic of acute inferior MI. Let's look at the 2 ED ECGs side by side: Limb leads Now you can see the differences more clearly Precordial Leads Acute ECG on the left, with slight STE in left precordial leads, compared to the previous ECG

2018 Dr Smith's ECG Blog

16. Bizarre (Hyperacute??) T-waves

Bizarre (Hyperacute??) T-waves Dr. Smith's ECG Blog: Bizarre (Hyperacute??) T-waves Tuesday, January 30, 2018 Thanks to one our great HCMC nurses, Ryan Burch. He figured this one out. A dialysis patient presented with dyspnea. He was a bit fluid overloaded and not hyperkalemic. This ECG was recorded: This was sent to me in a text that woke me from sleep, but not simultaneous with patient care. Truly bizarre T-waves in I, aVL, III, aVF, aVR Lead II is unremarkable, and leads V3-V6 are also (...) slightly bizarre. What do you think? My answer, as I looked with bleary eyes at my phone: "I have to say I've never seen this one before." Later, I looked into the chart and found an ECG from a few days before: I texted back: "Those T-waves were gone 5 minutes later. Artifact!" Ryan Burch, RN, was the nurse caring for the patient, later sent me the same ECG, stating the following: "This ECG had people stumped and concerned but I read an article in (see below) about an artifact a few weeks prior which I

2018 Dr Smith's ECG Blog

17. Chest pressure during exertion, evolution of inverted T-waves and Troponins. Surprise Angiogram.

Chest pressure during exertion, evolution of inverted T-waves and Troponins. Surprise Angiogram. Dr. Smith's ECG Blog: Chest pressure during exertion, evolution of inverted T-waves and Troponins. Surprise Angiogram. Sunday, July 1, 2018 I was texted this ED ECG with the words: "40-something with chest pressure during exertion." It is unclear whether the pain was gone at this time, but it was certainly better after receiving some sublingual nitro. Presentation ECG 1 What do you think? My (...) response was: "Definitely ischemia. Probable high lateral MI. If patient still has chest pain and you cannot relieve it with nitro, needs cath lab." This is because there is ST depression in II, III, aVF, and also in V4-V6, with STE and T-wave inversion in aVL. It looks as if there had been an occlusion resulting in STE in aVL (and reciprocal inferior STD), and that occlusion is now open so that the T-wave in aVL is now inverted (reperfusion T-wave), with reciprocally upright T-waves in inferior leads

2018 Dr Smith's ECG Blog

18. T-wave inversions and dynamic ST elevation

T-wave inversions and dynamic ST elevation Dr. Smith's ECG Blog: T-wave inversions and dynamic ST elevation Wednesday, April 18, 2018 Written by Pendell Meyers, with edits by Steve Smith I received a text message with no clinical information other than the following ECG, with the question "Is this Wellens? No prior ECG available." What do you think? I responded that this ECG represented benign T-wave inversion (BTWI), not Wellens. I asked for more history. It turns out this was a 25 year old (...) around 65 bpm. The QRS complex has moderately high voltage but otherwise normal morphology. There is STE in V1-V3 of 1.0, 1.5, and 1.5 millimeters, which is completely normal. There are prominent J-waves in leads V4-V6, as well as leads II, III, and aVF. Lead V3 shows the first and third complexes with terminal T-wave inversions, but the second complex does not appear to have this terminal T-wave inversion - whether this is due to a brief episode of baseline wandering / lead manipulation, or beat

2018 Dr Smith's ECG Blog

19. Besides the Nonspecific T-wave Inversion in aVL, What Else is Abnormal on this ECG?

Besides the Nonspecific T-wave Inversion in aVL, What Else is Abnormal on this ECG? Dr. Smith's ECG Blog: Besides the Nonspecific T-wave Inversion in aVL, What Else is Abnormal on this ECG? Saturday, April 14, 2018 This case was sent by Laszlo Farkas, a paramedic from Hungary. He discussed it with Janos Borbas MD and Robert Sepp MD from University of Szeged 2nd Department of Internal Medicine and Cardiology Clinic. The case inspired me to resurrect a case that I published 10 years ago (...) with the same ECG finding (2nd case below). What is the finding? What does it signify? Case An elderly male presented with chest pain. Here is the first ED ECG: Hint: the finding is NOT the T-wave inversion in aVL This ECG that I published 10 years ago in Critical Decisions in Emergency and Acute Care Electrocardiography has the same finding: What is the finding? The finding is an inverted U-wave, as demonstrated with arrows here: Inverted U-waves in a patient with chest pain are reported to be highly

2018 Dr Smith's ECG Blog

20. RBBB and inverted hyperacute T-wave in V3. Do not let negative posterior leads dissuade you!

RBBB and inverted hyperacute T-wave in V3. Do not let negative posterior leads dissuade you! Dr. Smith's ECG Blog: RBBB and inverted hyperacute T-wave in V3. Do not let negative posterior leads dissuade you! Saturday, May 26, 2018 An elderly male with history of MI 10 years prior called 911 for chest pain. Here is the prehospital ECG: What do you think? Computer only noted RBBB. There is sinus rhythm with RBBB. There is a bit of ST elevation in III and aVF, with reciprocal ST depression in aVL (...) . This is a subtle inferior MI. Is there more? In RBBB, there should be some ST depression in V1-V3, discordant to (in the opposite direction of) the R'-wave. But unless there is a huge R'-wave (as in RVH), this ST depression should not exceed 1 mm. And the inverted T-wave should be proportional. Here there is more than 1 mm of ST depression in lead V2, and the inverted T-wave in V3 is hyperacute . This is posterior STEMI. Moreover, look at V6. There is ST elevation with a hyperacute T-wave (there should never

2018 Dr Smith's ECG Blog

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