Is T wave inversion in lead V2 and a positive QRS complex with a negative T wave in lead 3 a real electrocardiogram (ECG) finding in a healthy 30-year-old?

From the Guidelines

T wave inversions in V2 and lead III with a positive QRS and negative T wave in a healthy 30-year-old can be normal variants, but further evaluation is necessary to rule out underlying cardiac conditions. When interpreting these ECG findings, it is essential to consider the patient's clinical context, including symptoms and family history. According to the international recommendations for electrocardiographic interpretation in athletes 1, T-wave inversion in the anterior leads can be a sign of arrhythmogenic right ventricular cardiomyopathy (ARVC) or hypertrophic cardiomyopathy (HCM). However, in the absence of concerning symptoms or family history, these findings may be benign, particularly in young adults, especially African Americans, where T-wave inversions in right precordial leads (V1-V3) can represent a persistent juvenile pattern 1.

• The patient's age and ethnicity should be taken into account when interpreting ECG findings, as certain patterns may be more common in specific populations.
• A positive QRS with negative T wave in lead III is frequently seen as a normal variant, but it is crucial to consider the entire clinical picture.
• If the patient is truly asymptomatic with no concerning history, these ECG patterns are likely benign, but further evaluation with an echocardiogram or referral to cardiology may be necessary to rule out underlying conditions.
• The key is correlating these ECG findings with the patient's complete clinical picture rather than viewing them in isolation, and considering the latest recommendations for electrocardiographic interpretation in athletes 1.

From the Research

T Wave Inversion in EKG

• T wave inversion in lead V2, along with a positive QRS and negative T wave in lead 3, can be an indicator of potential cardiac issues 2, 3, 4, 5.
• According to a study published in 2021, T-wave inversion in the anterior and lateral lead groups is independently associated with the risk of coronary heart disease (CHD), while lateral T-wave inversion is also associated with increased risk of mortality 2.
• Another study from 2020 highlights the complexity of interpreting T-wave inversion in athletes, suggesting that it may be a sign of underlying structural heart disease or life-threatening arrhythmogenic cardiomyopathies 3.
• A 2014 study found that isolated T-wave inversion is associated with an increased risk of sudden cardiac death (SCD) and death from all causes, with a hazard ratio of 3.30 4.
• A more recent study from 2025 analyzed the clinical significance of T wave depth and T wave/QRS voltage ratio in young individuals with T wave inversion, finding that deeper T waves and T wave inversion in multiple territories may be indicators of underlying cardiomyopathy 5.

Lead-Specific Findings

• Lead V2 T wave inversion may be associated with increased risk of CHD and mortality, particularly if accompanied by other abnormal ECG findings 2, 4.
• A positive QRS and negative T wave in lead 3 may be a normal variant, but can also be seen in individuals with cardiac disease 3, 5.
• The distribution of T wave inversion across multiple lead territories may be an indicator of underlying cardiomyopathy 5.

Clinical Significance

• T wave inversion, particularly in the anterior and lateral lead groups, should be viewed as a potential red flag on the ECG of young and apparently healthy individuals, warranting further investigation 2, 3, 4, 5.
• Deeper T waves and T wave inversion in multiple territories may be early indicators of underlying cardiomyopathy, highlighting the importance of careful ECG interpretation and follow-up evaluation 5.