What is the differential diagnosis and management for biphasic T waves in leads V2 and V3 on an electrocardiogram (ECG)?

Differential Diagnosis and Management of Biphasic T Waves in V2-V3

Immediate Clinical Significance

Biphasic T waves in V2-V3 with a negative component ≥1 mm in depth require urgent evaluation to exclude critical proximal left anterior descending (LAD) coronary artery stenosis (Wellens syndrome Type A) or underlying cardiomyopathy, particularly arrhythmogenic right ventricular cardiomyopathy (ARVC). 1

Key Differential Diagnoses

Critical LAD Stenosis (Wellens Syndrome Type A)

• Biphasic T waves in V2-V3 represent a pre-infarction state requiring urgent intervention 2, 3
• Typically occurs during pain-free periods after recent chest pain episodes 4, 2
• Associated with deep symmetrical T-wave inversions ≥2 mm when progressing to Type B pattern 5
• Failure to recognize this pattern leads to anterior wall myocardial infarction in the majority of cases 6, 7

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)

• Anterior TWI in V1-V2/V3 is a recognized ECG pattern in ARVC 8
• Absence of J-point elevation or presence of ST-segment depression makes ARVC more likely than athlete's heart 8
• Requires comprehensive evaluation including echocardiography, cardiac MRI, Holter monitoring, exercise ECG, and signal-averaged ECG 8

Normal Variants (Context-Dependent)

• In adolescents <16 years: anterior biphasic T waves are normal (juvenile pattern) 8
• In Black athletes: biphasic T waves in a single lead (most commonly V3) are considered normal 8
• In adult athletes: biphasic T waves in V3 alone may be normal when accompanied by J-point elevation and ST-segment elevation 8

Other Cardiomyopathies

• Hypertrophic cardiomyopathy (HCM): rarely presents with anterior T-wave changes but possible 8
• Left ventricular non-compaction: may present with T-wave abnormalities in multiple territories 5

Diagnostic Algorithm

Step 1: Immediate Risk Stratification

• Obtain detailed history focusing on: recent chest pain episodes (especially if resolved), syncope, family history of sudden cardiac death or cardiomyopathy 5, 1
• Age assessment: <16 years suggests juvenile pattern; adult requires full workup 8
• Ethnicity: Black athletes may have normal variant if limited to single lead with J-point elevation 8

Step 2: ECG Analysis

• Measure depth of negative component: ≥1 mm in ≥2 contiguous leads is pathological 1
• Assess for J-point elevation and ST-segment morphology: presence suggests benign athletic adaptation; absence or ST depression suggests ARVC or ischemia 8, 5
• Check for associated findings: QT prolongation increases specificity for LAD stenosis 8, 5

Step 3: Laboratory Testing

• Measure high-sensitivity troponin immediately to exclude acute myocardial injury 5, 1, 9
• Elevated troponin with biphasic T waves mandates urgent cardiology consultation 1

Step 4: Cardiac Imaging

• Transthoracic echocardiography is mandatory for all patients with pathological biphasic T waves to assess: left ventricular wall thickness, regional wall motion abnormalities, right ventricular size and function 5, 1, 9
• If echocardiography is non-diagnostic but clinical suspicion remains high: cardiac MRI with gadolinium is the gold standard 1, 9
• Cardiac MRI detects subtle myocardial abnormalities, fibrosis (late gadolinium enhancement), and apical/lateral wall hypertrophy missed on echo 1

Step 5: Risk-Based Advanced Testing

• For suspected Wellens syndrome (recent chest pain, pain-free presentation): urgent coronary angiography is indicated 4, 2, 3, 7
• For suspected ARVC: comprehensive evaluation including 24-hour Holter monitoring, exercise ECG testing, and signal-averaged ECG 8
• For "grey zone" left ventricular hypertrophy (13-16 mm in males): exercise ECG and Holter to detect ventricular arrhythmias 1

Management Based on Etiology

Wellens Syndrome (Critical LAD Stenosis)

• Urgent cardiac catheterization with percutaneous coronary intervention is definitive treatment 3, 7
• Avoid stress testing as it may precipitate myocardial infarction 2, 3
• Revascularization reverses both T-wave inversions and wall motion abnormalities 5

ARVC

• ICD implantation for symptomatic patients (syncope or prior sudden cardiac arrest) 5
• Ablation of abnormal epicardial late activation areas in right ventricle suppresses recurrent ventricular arrhythmias in >75% of patients 5
• Genetic counseling and family screening 9

Normal Variants

• No intervention required for: adolescents <16 years, Black athletes with single-lead involvement and J-point elevation, or athletes with J-point/ST elevation 8
• However, temporary restriction from athletic activity until evaluation is complete is prudent 8, 9

Long-Term Surveillance

For All Patients with Pathological Biphasic T Waves

• Serial cardiac imaging (echocardiography or cardiac MRI) at 6-12 month intervals initially, even if initial evaluation is normal 1, 9
• T-wave abnormalities may precede structural changes in cardiomyopathy by months to years 5, 1, 9
• More frequent monitoring for patients with family history of cardiomyopathy or sudden cardiac death 1

For Athletes Cleared to Return to Sport

• Regular follow-up with serial ECGs and echocardiography to monitor for development of cardiomyopathy phenotype 8

Critical Pitfalls to Avoid

• Never dismiss biphasic T waves as "non-specific" without proper evaluation—they represent the same pathological significance as frank T-wave inversion 1
• Do not perform stress testing in suspected Wellens syndrome—proceed directly to coronary angiography 2, 3
• Do not assume normal initial imaging excludes disease—cardiomyopathy may only become evident over time 5, 1, 9
• Verify proper lead placement before diagnosing pathology—lead misplacement can create pseudo-abnormalities 8