Discharge of Patients with T-Wave Abnormalities and Polarization Reversal
Hospitals may discharge patients with T-wave abnormalities and polarization reversal when these ECG findings are determined to be non-specific or low-risk after appropriate risk stratification and cardiac biomarker testing shows no evidence of acute myocardial injury.
Understanding T-Wave Abnormalities
T-wave abnormalities on ECG can represent a wide spectrum of clinical significance, ranging from benign variants to serious cardiac pathology:
- Marked (≥2 mm) symmetrical precordial T-wave inversion strongly suggests acute ischemia, particularly due to critical stenosis of the left anterior descending coronary artery 1, 2
- Nonspecific ST-segment and T-wave changes (ST-segment deviation <0.5 mm or T-wave inversion ≤2 mm) are less diagnostically helpful and may represent normal variants 1
- T-wave abnormalities can be the sole manifestation of ischemia in 74.4% of patients with non-ST-elevation acute coronary syndromes 3
- T-wave inversion can also be caused by non-cardiac conditions including central nervous system events and medications such as tricyclic antidepressants or phenothiazines 1
Risk Stratification Algorithm for Discharge Decision
Step 1: Evaluate ECG Characteristics
High-risk features (generally not suitable for discharge):
- Marked (≥2 mm) symmetrical precordial T-wave inversion
- T-wave inversion with concurrent ST-segment depression
- T-wave inversion in multiple contiguous leads
Lower-risk features (may be suitable for discharge):
- Nonspecific T-wave changes (<2 mm inversion)
- Isolated T-wave abnormalities without ST changes
- T-wave changes known to be chronic/unchanged from previous ECGs
Step 2: Cardiac Biomarker Assessment
- Serial cardiac biomarkers (troponin) must be negative 1
- A completely normal ECG in a patient with chest pain does not exclude ACS, as 1-6% of such patients may have NSTEMI 1
Step 3: Clinical Risk Assessment
- Patients with T-wave abnormalities but negative biomarkers and no high-risk features may be discharged if:
- No ongoing chest pain or ischemic symptoms
- No hemodynamic instability
- No arrhythmias
- No evidence of heart failure
Step 4: Consider Additional Testing
- For intermediate-risk cases, additional testing may be warranted before discharge:
- Rest echocardiography to assess wall motion
- Stress testing if appropriate (contraindicated with active ischemia)
- Radionuclide imaging 1
Specific Scenarios Where Discharge May Be Appropriate
Non-ischemic causes of T-wave changes:
- Respiratory variation in T-wave morphology (T-waves normalize with held respiration) 4
- Known medication effect
- Known chronic T-wave changes
Low-risk clinical profile:
- Young patients without cardiac risk factors
- Normal cardiac biomarkers
- Resolution of symptoms
- No wall motion abnormalities on imaging
Alternative diagnosis established:
- Musculoskeletal chest pain with incidental T-wave changes 4
- Other non-cardiac cause of symptoms clearly identified
Important Caveats and Pitfalls
- T-wave abnormalities should not automatically be regarded as benign phenomena, especially in patients with risk factors for coronary artery disease 3
- Patients with abnormal T-waves in specific patterns have significantly higher risk of death, acute MI, and refractory angina (11% vs 3%) 3
- T-wave inversion may be the only ECG manifestation of myocardial edema in non-ST-elevation acute coronary syndromes 5
- Positive or flat T-waves in lead aVR are associated with increased risk of sudden cardiac death 6
Conclusion for Clinical Practice
When evaluating patients with T-wave abnormalities, clinicians must balance the risk of missing acute cardiac pathology against unnecessary hospitalizations. The decision to discharge should be based on a comprehensive assessment of ECG characteristics, cardiac biomarkers, clinical presentation, and risk factors. When in doubt, additional cardiac testing or observation is warranted, particularly for patients with new T-wave changes, multiple risk factors, or concerning symptoms.