Is T wave inversion in lead V2 on an electrocardiogram (ECG) in a healthy 30-year-old real or an artifact?

From the Guidelines

T wave inversion in lead V2 on an ECG in a healthy 30-year-old can be a normal variant, particularly in individuals of African or Caribbean origin, where it is commonly observed in up to 25% of cases, as noted in the European Heart Journal study 1.

Clinical Context

When evaluating T wave inversion in a healthy 30-year-old, it is crucial to consider the clinical context, including symptoms, cardiac risk factors, and family history of sudden cardiac death.

• Asymptomatic patients with no cardiac risk factors and a normal ECG otherwise may not require further evaluation, as the isolated finding of T wave inversion in lead V2 is likely benign.
• However, if there are accompanying symptoms like chest pain, shortness of breath, palpitations, or syncope, additional evaluation is warranted.
• The presence of other ECG abnormalities, such as ST segment changes, pathological Q waves, or T wave inversions in multiple leads, would also prompt further investigation.

Diagnostic Approach

In cases of uncertainty, the following diagnostic approaches may be considered:

• Comparison with previous ECGs to assess for any changes or persistence of T wave inversion.
• Exercise stress testing to evaluate for any ischemic changes or arrhythmias.
• Echocardiography to assess for any structural heart disease, such as hypertrophic cardiomyopathy or arrhythmogenic right ventricular dysplasia, as recommended in the Journal of the American College of Cardiology study 1.
• Consideration of cardiac magnetic resonance (CMR) imaging, especially if there is a high suspicion of cardiomyopathy or other structural heart disease.

Recommendations

Based on the most recent and highest quality study, the 2017 international recommendations for electrocardiographic interpretation in athletes 1 suggest that T wave inversion in the lateral or inferolateral leads, such as lead V2, may be a normal variant in healthy athletes, but further evaluation is recommended to exclude underlying cardiac disease, such as hypertrophic cardiomyopathy or arrhythmogenic right ventricular dysplasia.

• Echocardiography is recommended as the initial evaluation, with consideration of CMR imaging if the echocardiogram is abnormal or if there is a high clinical suspicion of cardiomyopathy.
• Annual follow-up testing is recommended throughout the athletic career in athletes with normal results.
• Family evaluation and genetic screening may be considered if there is a family history of sudden cardiac death or cardiomyopathy.

From the Research

T Wave Inversion in Healthy 30-Year-Old EKG

• T wave inversion in the anterior lead group, which includes lead V2, has been associated with an increased risk of coronary heart disease (CHD) 2.
• A study found that anterior T-wave inversions were independently associated with the risk of CHD, with a hazard ratio of 2.37 2.
• However, another study found that cardiomyopathy diagnoses were not associated with abnormal T-wave inversions in the anterior territory, but rather with deeper maximum T-wave inversion depth and the presence of abnormal T-wave inversions in the lateral territory 3.
• It is worth noting that T-wave inversion in lead V2 can be a benign phenomenon, especially if it is an isolated finding 3.
• Exercise stress testing may be useful in evaluating T-wave inversions, as it can help to identify patients with cardiac pathology 4, 5.
• However, the utility of exercise stress testing in pediatric patients with T-wave inversions is limited, and it may not be indicated for routine use in this population 5.

Lead-Specific T Wave Inversion

• T-wave inversion in the lateral lead group is associated with an increased risk of mortality, with a hazard ratio of 1.51 2.
• T-wave inversion in the inferior lead group is generally considered to be a benign phenomenon 2, 3.
• Cardiomyopathy diagnoses were more strongly associated with certain patterns of abnormal T-wave inversions, including deeper maximum T-wave inversion depth and the presence of abnormal T-wave inversions in the lateral territory 3.

Clinical Implications

• The presence of T-wave inversion in lead V2 should be evaluated in the context of the patient's overall clinical presentation and other EKG findings 2, 3.
• Further testing, such as echocardiography or exercise stress testing, may be necessary to evaluate the significance of T-wave inversion in lead V2 3, 4, 5.