What does an EKG (electrocardiogram) showing poor quality data on leads II, AVL, and AVF, with a sinus rhythm and inverted T waves on leads B1 and B2, indicate for a female patient?

EKG Interpretation: Poor Quality Data with Sinus Rhythm and Inverted T Waves

What This EKG Finding Means

The report indicates technical issues with lead quality (leads II, aVL, aVF) making those leads unreliable, while showing normal sinus rhythm with inverted T waves in leads V1 and V2, which may be normal or require further evaluation depending on your age and clinical context. 1

Understanding the Components

Poor Quality Data on Leads II, aVL, aVF

• "Poor quality data" means these specific leads had technical problems—likely from poor electrode contact, patient movement, or electrical interference—making them uninterpretable 2
• This is an operator-dependent error that requires repeating the EKG with proper electrode placement and patient positioning to obtain diagnostic-quality tracings 2
• These leads are critical for evaluating the inferior and lateral aspects of the heart, so a repeat EKG is necessary for complete cardiac assessment 1

Sinus Rhythm

• This is normal and reassuring—your heart is beating in a regular pattern originating from the normal pacemaker (sinus node) 1
• No arrhythmia or conduction abnormality is present 1

Inverted T Waves in V1 and V2

The clinical significance depends entirely on your age and whether this extends beyond V2:

If You Are Under 20 Years Old:

• T wave inversion in V1 and V2 is completely normal in children older than 1 month, adolescents, and young adults under 20 years 1
• This represents a normal developmental pattern called the "juvenile ECG pattern" and requires no further evaluation 1

If You Are 20 Years or Older:

• T wave inversion in V1 alone is normal in adults 1, 3
• T wave inversion in both V1 and V2 is uncommon in healthy adults (<1.5% of cases) and warrants further evaluation 3
• This pattern may represent early manifestations of cardiac disease before structural changes become detectable on imaging 3

Immediate Action Required

You need a repeat EKG with proper lead placement to obtain diagnostic-quality tracings from leads II, aVL, and aVF. 2

Further Evaluation Algorithm (If Age ≥20 Years)

Step 1: Clinical Assessment

• Document any cardiac symptoms: chest pain, shortness of breath, palpitations, syncope, or exercise intolerance 4, 3
• Obtain detailed family history of sudden cardiac death, cardiomyopathy, or inherited heart disease 4, 3
• Review medications that can cause T wave changes (tricyclic antidepressants, phenothiazines) 5

Step 2: Repeat EKG with Comparison

• Obtain high-quality 12-lead EKG with proper electrode placement 2
• Compare with any prior EKGs to identify new changes versus chronic findings 5
• Assess whether T wave inversion extends beyond V2 into V3 or other leads 3

Step 3: Risk Stratification Based on T Wave Distribution

If T wave inversion is limited to V1-V2 only:

• Check cardiac biomarkers (troponin) to exclude acute injury 4, 3
• Perform transthoracic echocardiography to exclude structural heart disease 4, 3
• If initial evaluation is normal, continue clinical surveillance with serial ECGs and echocardiography 3

If T wave inversion extends to V3 or involves lateral/inferior leads:

• This is highly concerning for cardiomyopathy (particularly arrhythmogenic right ventricular cardiomyopathy or hypertrophic cardiomyopathy) 1, 4
• Immediate echocardiography is mandatory 4, 3
• Cardiac MRI with gadolinium enhancement is recommended if echocardiography is non-diagnostic 4
• Cardiology consultation is required 3

Common Pitfalls to Avoid

• Do not dismiss poor quality leads—they must be repeated for complete cardiac assessment 2
• Do not assume T wave inversion in V1-V2 is always benign in adults ≥20 years without proper evaluation 3
• Do not overlook non-cardiac causes including central nervous system events, electrolyte abnormalities, or medication effects 5
• Do not rely on a single normal echocardiogram to exclude cardiac disease—T wave abnormalities may precede structural changes, requiring ongoing surveillance 4, 3

Special Considerations

If You Are an Athlete:

• T wave inversion beyond V1 in athletes requires comprehensive evaluation to exclude inherited cardiovascular disease 1
• Black athletes may have normal T wave inversion in V2-V4 when preceded by J-point elevation and convex ST-segment elevation 1

If You Have Symptoms:

• New T wave inversions with chest pain or shortness of breath require immediate emergency department evaluation for acute coronary syndrome 5
• Obtain immediate ECG, cardiac biomarkers, and risk stratification 5

Bottom Line

The poor quality data requires a repeat EKG immediately. The T wave inversions in V1-V2 may be normal if you are under 20 years old, but require systematic evaluation if you are 20 or older—starting with a proper repeat EKG, clinical assessment, cardiac biomarkers, and echocardiography. 1, 4, 3, 2