From the Guidelines
T wave inversion of 2 mm in two or more adjacent leads is a significant finding that requires further evaluation to exclude underlying cardiomyopathy or other cardiac disease, as recommended by the European Heart Journal in 2010 1. When interpreting T wave inversion, it is essential to consider the clinical context and patient population. In healthy athletes of African/Caribbean origin, inverted T-waves in leads V2-V4 may be a normal variant, but T-wave inversion in inferior or lateral leads warrants further investigation 1. Some key points to consider when evaluating T wave inversion include:
- T-wave inversion may be a sign of inherited heart muscle disease, even in the absence of other features or structural changes in the heart 1
- Athletes with post-pubertal persistence of T-wave inversion beyond V1 require further clinical and echocardiographic evaluation to exclude underlying cardiomyopathy 1
- The significance of minor T-wave changes, such as flat or minimally inverted T-waves, is unclear, but these changes may be a benign phenomenon resulting from increased vagal tone or may have a pathological basis 1 In clinical practice, I recommend checking serum electrolytes, particularly potassium levels, and evaluating for symptoms of cardiac ischemia if T wave inversion is found on an ECG, as electrolyte imbalances or myocardial damage can alter T wave morphology 1. Additionally, considering the patient's clinical presentation and other diagnostic information is crucial when interpreting ECG findings, as a completely normal ECG does not exclude the possibility of acute coronary syndrome (ACS) 1. It is also important to note that the ECG is a critical diagnostic tool in cardiology, and its proper interpretation contributes significantly to the diagnosis and management of patients with cardiac disorders 1.
From the Research
T Wave Abnormalities
- T wave abnormalities can be an indicator of various cardiac conditions, including hyperkalemia 2, 3
- Peaked T waves are a common electrocardiographic manifestation of hyperkalemia, but are rarely a sign of life-threatening hyperkalemia 2
- T wave inversions can be a sign of underlying cardiac pathology, and require careful clinical history taking and physical examination to accurately identify the cause 4
Risk of Sudden Cardiac Death
- T wave abnormalities, including inversions, can be associated with an increased risk of sudden cardiac death (SCD) 5, 6
- The identification of patients at risk for SCD is a significant challenge, and noninvasive identification of high-risk patients is an area of great interest 5
- T wave changes can be an early marker of underlying cardiovascular disease, and even minor ST-T abnormalities have been associated with reduced survival and increased risk of SCD 5