Can you interpret this ECG (sinus rhythm 83 bpm, PR interval 170 ms, QRS duration 88 ms, QTc 444 ms) with anterior T‑wave inversion for possible ischemia?

ECG Interpretation: Anterior T-Wave Inversion with Borderline QTc

This ECG shows concerning anterior T-wave inversions that require urgent evaluation for acute coronary syndrome, particularly critical proximal left anterior descending (LAD) coronary artery stenosis, which carries high risk if managed with medical therapy alone.

Immediate Risk Assessment

Your ECG demonstrates several high-risk features that demand urgent action:

• T-wave inversions in anterior leads are highly suggestive of acute myocardial ischemia, particularly when associated with critical stenosis of the proximal LAD 1
• The QTc of 444 ms (borderline prolonged) combined with T-wave inversions adds additional arrhythmic risk, especially if structural heart disease is present 1
• T-wave inversion depth ≥1 mm in leads with dominant R waves is considered abnormal and warrants investigation in the appropriate clinical context 2, 1
• If these inversions are ≥2 mm deep in precordial leads, this strongly suggests critical LAD stenosis with anterior wall hypokinesis and represents a very high-risk pattern 1

Critical Next Steps

If You Have ANY Symptoms (Chest Pain, Dyspnea, Diaphoresis):

Treat this as acute coronary syndrome until proven otherwise 1:

• Immediate emergency department evaluation within 10 minutes: obtain 12-lead ECG, check vital signs, establish IV access, administer aspirin 162-325 mg, obtain cardiac biomarkers (troponin), and provide continuous monitoring 1
• Chest pain >20 minutes represents a critical threshold where myocardial infarction must be strongly considered given the established relationship between treatment delay and mortality 1
• New T-wave inversion in multiple precordial leads (≥2 mm depth) indicates high likelihood of ACS and suggests critical LAD stenosis, often associated with anterior wall hypokinesis 1

If You Are Asymptomatic:

Mandatory evaluation is still required because T-wave inversions in anterior leads are clinically particularly important 1:

• Compare with prior ECGs immediately if available, as this significantly improves diagnostic accuracy and helps identify new changes 1, 3
• Obtain cardiac biomarkers (troponin) to rule out silent myocardial injury, as T-wave inversion with elevated troponin may represent myocarditis or NSTEMI 3
• Transthoracic echocardiography is mandatory to assess for anterior wall motion abnormalities, left ventricular function, and structural heart disease 1, 4

Understanding the ECG Findings

Normal vs. Abnormal T-Wave Inversions:

• In adults ≥20 years, T waves should be upright in leads I, II, and V3-V6; any inversion in these leads warrants investigation 1
• T-wave inversion in V1-V2 alone may be a normal variant in some adults, but requires careful evaluation to exclude high-risk conditions including critical LAD stenosis, cardiomyopathy, and intracranial pathology 1
• The axis of T: -10 degrees is abnormal and suggests anterior T-wave abnormalities extending beyond just V1-V2 1

Depth Thresholds That Matter:

• T-wave inversion ≥1 mm (0.1 mV) in two or more contiguous leads with dominant R waves is abnormal 2, 1
• T-wave inversion ≥2 mm (0.2 mV) in precordial leads strongly suggests acute myocardial ischemia, particularly critical proximal LAD stenosis 1
• Deep symmetrical T-wave inversion in anterior chest leads is often related to significant stenosis of the proximal LAD 2

Differential Diagnosis Beyond Ischemia

While ischemia is the primary concern, consider these alternative causes:

• Myocarditis (especially post-COVID-19): presents with T-wave inversions, elevated troponin, but preserved LV function 1
• Takotsubo (stress) cardiomyopathy: deep T-wave inversions after emotional stress with normal coronaries on angiography 3
• Central nervous system events (intracranial hemorrhage): can produce deep T-wave inversions with QT prolongation 1
• Medications: tricyclic antidepressants and phenothiazines can cause deep T-wave inversion 1
• Hypertrophic cardiomyopathy: T-wave inversion may be the only sign of inherited heart muscle disease even before structural changes are detectable 1

Risk-Stratified Management Algorithm

High-Risk Features Present (Any of These):

• Chest pain >20 minutes
• T-wave inversions ≥2 mm in multiple precordial leads
• Hemodynamic instability
• Elevated troponin

Action: Immediate emergency department evaluation → continuous monitoring → serial cardiac biomarkers → coronary angiography if troponin elevated or ongoing symptoms 1

Intermediate-Risk Features:

• Brief chest discomfort or atypical symptoms
• T-wave inversions 1-2 mm depth
• No prior cardiac history

Action: Admission to chest pain unit → serial cardiac biomarkers over 6-12 hours → stress testing before discharge if biomarkers negative 1

Lower-Risk (Asymptomatic):

• No symptoms
• Incidental finding
• T-wave inversions <1 mm

Action: Outpatient evaluation with echocardiography as mandatory first test → cardiac MRI if echocardiogram non-diagnostic → stress testing or coronary evaluation if age ≥30 years with risk factors 1, 4

Critical Pitfalls to Avoid

• Do not assume non-specific changes are benign: even non-specific T-wave abnormalities are associated with increased cardiovascular mortality 3
• Do not miss posterior MI: approximately 4% of acute MIs present with non-diagnostic standard 12-lead ECGs, requiring posterior leads V7-V9 for detection 3
• Do not overlook left circumflex occlusion: can present with non-diagnostic 12-lead ECG 3
• Do not ignore the QTc: prolonged QTc combined with T-wave inversions increases arrhythmic risk, particularly when structural heart disease is present 1

Prognostic Significance

• Patients with marked symmetrical precordial T-wave inversion (≥2 mm) often exhibit anterior wall hypokinesis and are at high risk if given medical treatment alone 1
• Revascularization will often reverse both the T-wave inversion and wall-motion disorder in ischemic cases 1
• Even in the absence of symptoms, T-wave inversions in anterior leads require comprehensive cardiac evaluation as they may represent the only sign of inherited heart muscle disease 1

Bottom Line

Do not delay evaluation of anterior T-wave inversions. The combination of your ECG findings (anterior T-wave inversions, borderline QTc, sinus rhythm at 83 bpm) requires at minimum an echocardiogram and troponin measurement, with urgent cardiology consultation if you have any symptoms or if troponin is elevated 1, 4.