What is the clinical significance of T wave inversion in leads V2 and V3 (electrocardiogram leads)?

Clinical Significance of T Wave Inversion in Leads V2 and V3

T wave inversion in leads V2 and V3 may indicate severe stenosis of the proximal left anterior descending coronary artery, especially when deeply inverted (>0.5 mV) and accompanied by QT prolongation. 1

Pathophysiological Significance

• T wave inversion in precordial leads V2 and V3 can represent a specific pattern known as Wellens' syndrome when accompanied by a history of chest pain that has resolved, indicating critical stenosis of the proximal left anterior descending (LAD) coronary artery 2

• Deeply inverted T waves (>0.5 mV) in leads V2, V3, and V4, especially with QT prolongation, strongly correlate with severe proximal LAD stenosis with collateral circulation, even in the absence of ongoing chest pain or other ECG evidence of infarction 1

• If not recognized and treated appropriately, patients with this pattern have a high risk of developing acute anterior wall myocardial infarction with its associated mortality and morbidity 1

Differential Diagnosis

T wave inversion in V2-V3 can be seen in several conditions:

• Acute coronary syndrome or impending myocardial infarction (Wellens' syndrome) 2

• Recent intracranial hemorrhage (cerebrovascular accident pattern) 1

• Normal variant in certain populations:

  • Children older than 1 month (normal finding) 1
  • Adolescents under 16 years of age (juvenile T wave pattern) 1
  • Young adults less than 20 years of age 1
  • Black athletes (can be a normal repolarization pattern) 1

• Other cardiac conditions:

  • Certain forms of cardiomyopathy 1
  • Post-ischemic changes following a resolved myocardial infarction 1
  • Reperfusion of a previously occluded coronary artery 3

Clinical Implications and Risk Assessment

• T wave inversion in V2-V3 with QT prolongation in a patient with recent chest pain requires urgent evaluation, even if the pain has resolved and cardiac biomarkers are normal 2

• In anterior STEMI, T wave inversion in leads with ST elevation may actually indicate spontaneous reperfusion, with one study showing 100% of anterior STEMI patients with T wave inversion had patent infarct-related arteries before intervention 3

• The presence of profound ST-segment shift or T wave inversion involving multiple leads/territories correlates with a greater degree of myocardial ischemia and worse prognosis 1

Evaluation Algorithm

For patients presenting with T wave inversion in V2-V3:

1. Assess for clinical context:

   • History of recent chest pain (even if resolved) 2
   • Age of patient (may be normal in young patients) 1
   • Race (may be normal variant in Black individuals) 1

2. Evaluate ECG characteristics:

   • Depth of T wave inversion (>0.5 mV is more concerning) 1
   • Presence of QT prolongation (increases specificity for LAD stenosis) 1
   • Distribution of T wave changes (isolated to V2-V3 vs. more widespread) 1

3. Recommended workup for concerning T wave inversions:

   • Cardiac biomarkers to assess for myocardial injury 1
   • Echocardiography to evaluate for wall motion abnormalities 1
   • Consider urgent coronary angiography for high-risk patterns, especially with history of chest pain 2

Important Caveats

• Respiratory variation can cause T wave changes that mimic pathologic T wave inversion; repeating the ECG with held respiration may help differentiate physiologic from pathologic causes 4

• T wave inversion in lead aVL, though not the focus of this question, has been associated with mid-segment LAD lesions and should not be overlooked when evaluating the ECG 5

• The pattern of T wave inversion in inferior leads (II, III, aVF) can represent an "inferior Wellens sign" indicating critical stenosis of the right coronary artery or left circumflex artery 6