From the Guidelines
The finding of negative T waves in leads V1, V2, and D3 with a short PR interval suggests a possible Wolff-Parkinson-White (WPW) syndrome or another pre-excitation syndrome, and patients with this finding should be referred to a cardiologist or electrophysiologist for comprehensive assessment. WPW syndrome is characterized by an accessory electrical pathway between the atria and ventricles that bypasses the normal conduction system, resulting in early ventricular activation 1. The short PR interval (typically less than 120 milliseconds) reflects this rapid conduction, while the negative T waves in the specified leads may indicate repolarization abnormalities. This pattern requires further evaluation with a complete 12-lead ECG to look for delta waves, which are slurred upstrokes of the QRS complex that are characteristic of WPW.
Key Considerations
- The diagnosis of pre-excitation is solely based on the findings of the surface ECG, and intermittent pre-excitation is not uncommon in newborns and infants 1.
- The T-wave abnormalities can occur in the presence or absence of ST-segment abnormalities, and interpreting isolated T-wave abnormalities is difficult and often the source of ambiguous and inaccurate statements 1.
- The 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay provides definitions for various conduction disorders, including WPW syndrome 1.
Treatment Options
- Observation for asymptomatic patients
- Antiarrhythmic medications like flecainide or propafenone for symptomatic patients
- Catheter ablation of the accessory pathway, which is often curative and considered first-line therapy for symptomatic patients It is essential to note that WPW can be associated with paroxysmal supraventricular tachycardias and, rarely, sudden cardiac death, emphasizing the need for prompt and accurate diagnosis and treatment 1.
From the Research
Significance of a Negative T Wave in Leads V1, V2, and D3 with a Short PR Interval
- A negative T wave in leads V1, V2, and D3 with a short PR interval can be indicative of Wolff-Parkinson-White (WPW) syndrome, a pre-excitation syndrome characterized by a short PR interval, a prolonged QRS interval, and an initial slurring of the QRS complex called a delta wave 2, 3.
- WPW syndrome is caused by the presence of accessory atrioventricular conduction fibers, which can lead to a wide range of symptoms, including palpitations, tachydysrhythmias, and sudden cardiac death 2.
- The presence of a short PR interval and a negative T wave in leads V1, V2, and D3 may also be associated with other conditions, such as fasciculoventricular fibers (FVFs), which are responsible for 1%-5% of cases of asymptomatic preexcitation on the surface electrocardiogram (ECG) 4.
- However, the study of FVFs and WPW syndrome suggests that a higher delta wave amplitude is an independent risk factor for the presence of WPW syndrome and can accurately distinguish WPW syndrome from a FVF with good test accuracy characteristics 4.
- It is also important to note that T-wave inversions in inferior leads can be an early warning sign of impending myocardial infarction, and careful attention to the T-waves during asymptomatic periods may assist in identifying patients with critical stenosis of an underlying coronary artery 5.
- In addition, a Brugada ECG pattern, characterized by a positive terminal deflection and ST segment elevation in the right precordial leads, can be associated with a risk of sudden death, and patients with this pattern should be carefully evaluated and managed 6.