From the Guidelines
The management approach for patients presenting with T wave inversions should prioritize a systematic evaluation based on the location and extent of the inversions, as outlined in the international recommendations for electrocardiographic interpretation in athletes 1.
Key Considerations
- The location of T wave inversions is crucial in determining the potential underlying cardiac disease, with inversions in the lateral or inferolateral leads suggesting hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), left ventricular non-compaction (LVNC), arrhythmogenic right ventricular cardiomyopathy (ARVC), or myocarditis.
- Echocardiography is recommended as the initial evaluation for T wave inversions in the lateral or inferolateral leads, with cardiac magnetic resonance (CMR) considered a routine diagnostic test for detecting apical HCM, LVH localized to the free lateral wall, ARVC with predominant left ventricular involvement, and myocarditis 1.
- For T wave inversions isolated to the inferior leads, echocardiography is also recommended, with consideration of CMR based on echocardiography findings or clinical suspicion.
- In cases of T wave inversions in the anterior leads, echocardiography and CMR are recommended, with additional testing such as exercise ECG, minimum 24-hour ECG monitoring, and signal-averaged ECG (SAECG) considered based on clinical suspicion for ARVC.
Diagnostic Approach
- Initial evaluation should include a thorough history, physical examination, 12-lead ECG, and basic laboratory tests.
- Further diagnostic testing may include serial ECGs, echocardiography, stress testing, or coronary angiography based on risk assessment.
- CMR should be considered a routine diagnostic test for detecting underlying cardiac disease, particularly in cases of T wave inversions in the lateral or inferolateral leads.
Management
- Management should be tailored to the underlying cardiac disease, with consideration of medical therapy, lifestyle modifications, and risk stratification for athletic participation.
- Patients with confirmed cardiac disease should be referred to a cardiologist or heart rhythm specialist for further evaluation and management.
- Annual follow-up testing is recommended throughout the athletic career in athletes with normal results, with consideration of family evaluation and genetic screening if available 1.
From the Research
Management Approach for T Wave Inversions
The management approach for patients presenting with T wave inversions depends on the underlying cause of the inversion.
- In some cases, T wave inversions can be a normal variant, especially in asymptomatic adults 2.
- However, in patients with chest pain, T wave inversions can be a sign of underlying coronary artery disease or other cardiac conditions 2.
- The presence of T wave inversions in athletes can be a potential red flag for underlying structural heart disease or life-threatening arrhythmogenic cardiomyopathies 3.
- In patients with acute anterior ST elevation myocardial infarction, T wave inversions can be associated with patency of the infarct-related artery 4.
- Terminal T wave inversions on presentation can predict unfavorable in-hospital outcomes in STEMI patients treated with urgent percutaneous coronary intervention 5.
Diagnostic Evaluation
The diagnostic evaluation of patients with T wave inversions should include:
- A 12-lead electrocardiogram (ECG) to assess the pattern and distribution of the T wave inversions 6, 2.
- Echocardiography to evaluate left ventricular function and rule out structural heart disease 2.
- Stress testing or coronary angiography to assess for coronary artery disease 2, 4.
- Precordial ECG mapping to differentiate between coronary artery disease and other causes of T wave inversions 2.
Treatment
The treatment of patients with T wave inversions depends on the underlying cause of the inversion.
- In patients with coronary artery disease, treatment may include percutaneous coronary intervention or coronary artery bypass grafting 2, 4.
- In patients with structural heart disease or arrhythmogenic cardiomyopathies, treatment may include medication, implantable cardioverter-defibrillators, or other interventions 3.
- In patients with T wave inversions due to cardiac memory, treatment may include adjustment of pacemaker settings or other interventions to minimize the effects of cardiac memory 6.