What are concerning findings of T waves in a pediatric electrocardiogram (EKG)?

From the Guidelines

Concerning T wave findings in a pediatric EKG include T wave inversions in leads where they should be upright, particularly in the left precordial leads (V5-V6), which may indicate myocardial ischemia or strain. When interpreting pediatric EKGs, it's essential to consider age-specific norms, as T wave patterns normally evolve throughout childhood 1. Tall, peaked T waves can suggest hyperkalemia, while flattened or inverted T waves might indicate hypokalemia or hypocalcemia. T wave alternans (beat-to-beat variation in T wave amplitude or morphology) is particularly concerning as it may precede ventricular arrhythmias. Prolonged QT intervals with abnormal T wave morphology could indicate congenital long QT syndrome, placing the child at risk for sudden cardiac death. Deeply inverted, symmetric T waves may suggest hypertrophic cardiomyopathy, especially in adolescents. T wave abnormalities should always be interpreted in clinical context, considering the patient's symptoms, family history, and physical examination findings. Prompt cardiology consultation is warranted for unexplained concerning T wave abnormalities, especially with symptoms like syncope, chest pain, or palpitations. In neonates and infants, the TP segment is the preferred reference for the isoelectric line, and changes of ≥1 mm above the isoelectric line may be considered clinically significant 1. It's crucial to note that T wave patterns in children can vary, and T wave inversions in leads V1, V2, and V3 are common in children older than 1 month, but T wave inversions in leads V5 and V6 are more concerning and may indicate underlying cardiac issues. Considering the most recent evidence from 1, which provides updated practice standards for electrocardiographic monitoring in hospital settings, it's essential to prioritize the clinical context and age-specific norms when interpreting pediatric EKGs. Key points to consider when evaluating T wave abnormalities in pediatric EKGs include:

• Age-specific norms for T wave patterns
• Clinical context, including symptoms and physical examination findings
• Family history of cardiac conditions
• Presence of underlying cardiac conditions, such as congenital heart defects
• Prompt cardiology consultation for unexplained concerning T wave abnormalities.

From the Research

Concerning Findings of T Waves in a Pediatric Electrocardiogram (EKG)

• Inverted T waves can represent various pathologies or nonspecific changes, but deep (giant) inverted T waves are associated with specific clinical conditions such as apical hypertrophic cardiomyopathy, raised intracranial pressure, and severe myocardial ischemia 2.
• Bifid T waves in leads V2 and V3 can be a normal variant in children, with a high incidence of 18.3% in a study of 604 consecutive children free from clinically detectable heart disease 3.
• T-wave inversion in lateral ECG leads can be suspicious of cardiac pathology, but many pediatric patients with this finding have structurally normal hearts 4.
• T-wave inversions in right precordial leads V1 to V3 are relatively common in children and adolescents, but can also be a presentation of arrhythmogenic right ventricular cardiomyopathy 5.
• Deeply inverted and biphasic T-waves, as seen in Wellens' syndrome, can be a characteristic electrocardiographic pattern associated with critical stenosis of the proximal left anterior descending coronary artery, although this is more commonly seen in adults 6.