Differential Diagnosis for T Wave Inversion in V1-6 and Lead 2-3

Single Most Likely Diagnosis

• Ischemic Heart Disease: This is the most common cause of T wave inversion in the precordial leads (V1-6) and the limb leads (2-3). The inversion of T waves in these leads can indicate myocardial ischemia or infarction, particularly if the patient presents with chest pain or other symptoms suggestive of acute coronary syndrome.

Other Likely Diagnoses

• Left Ventricular Hypertrophy (LVH): T wave inversion can be seen in patients with LVH, especially in the lateral leads (V5, V6, I, and aVL) but can also involve the anterior precordial leads. The presence of LVH can be suggested by increased QRS complex voltages and may be associated with systemic hypertension.
• Bundle Branch Blocks: Both left and right bundle branch blocks can cause T wave inversions due to the altered ventricular depolarization and repolarization patterns. The T wave inversions typically occur in leads with a predominantly negative QRS complex.
• Pericarditis: Acute pericarditis can cause diffuse T wave inversions across the precordial and limb leads, although the ST segment elevation is more characteristic. The T wave inversions may occur in the subacute phase.

Do Not Miss Diagnoses

• Pulmonary Embolism: Although less common, pulmonary embolism can cause T wave inversions, particularly in the anterior leads (V1-4), as part of the classic S1Q3T3 pattern or as isolated findings. Given the high mortality of untreated pulmonary embolism, it is crucial not to miss this diagnosis.
• Cardiac Tamponade: While more typically associated with low QRS voltages and electrical alternans, cardiac tamponade can also cause T wave inversions due to the compression of the heart and altered repolarization patterns.

Rare Diagnoses

• Hypokalemia: Severe hypokalemia can cause T wave flattening or inversion, particularly in the precordial leads, although this is less common and usually accompanied by other ECG changes such as U waves.
• Myocarditis: Inflammation of the myocardium can lead to T wave inversions among other ECG abnormalities, reflecting the involvement of the myocardium in the inflammatory process.
• Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC): This condition can cause T wave inversions in the right precordial leads (V1-3) due to the replacement of the right ventricular myocardium by fatty tissue, leading to abnormal repolarization patterns.