In a 51‑year‑old man with bicuspid aortic valve, aortic insufficiency and hypertension who had chest pain two days ago, which single condition most likely accounts for the prominent T‑wave inversions in the anterior precordial leads (V2‑V3): non‑Q‑wave myocardial infarction (Wellens’ syndrome), Takotsubo syndrome, evolving pericarditis, central nervous system pathology (e.g., intracranial hemorrhage), or apical hypertrophic cardiomyopathy?

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Last updated: February 12, 2026 • View editorial policy

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Prominent T-Wave Inversions in a 51-Year-Old with Bicuspid Aortic Valve and Recent Chest Pain

In this clinical context, the prominent T-wave inversions are most likely attributable to apical hypertrophic cardiomyopathy (option e), though non-Q wave MI with Wellens' syndrome (option a) remains a critical competing diagnosis that must be urgently excluded.

Primary Diagnostic Consideration: Apical Hypertrophic Cardiomyopathy

The combination of bicuspid aortic valve, aortic insufficiency, hypertension, and prominent anterior T-wave inversions creates a high pretest probability for apical hypertrophic cardiomyopathy. 1

Supporting Evidence for Apical HCM

  • Bicuspid aortic valve patients have increased prevalence of left ventricular hypertrophy and associated cardiomyopathies, making structural heart disease the leading consideration in this population 1

  • Prominent T-wave inversions (≥2 mm) in anterior precordial leads are a hallmark ECG finding in apical hypertrophic cardiomyopathy, often occurring in the absence of acute ischemia 1, 2

  • Lateral or inferolateral T-wave inversion is common in primary myocardial disease and warrants echocardiography and cardiac MRI evaluation 1

  • T-wave inversion may represent the only sign of inherited heart muscle disease even before structural changes can be detected on standard imaging 1

Critical Competing Diagnosis: Wellens' Syndrome (Non-Q Wave MI)

Despite the structural heart disease context, Wellens' syndrome must be immediately excluded because it represents a pre-infarction state with critical proximal LAD stenosis that requires urgent revascularization. 3, 4

High-Risk Features of Wellens' Pattern

  • Deep symmetrical T-wave inversions ≥2 mm in anterior chest leads (V2-V4) are the classic ECG pattern associated with critical proximal LAD stenosis 1, 2, 3

  • Patients with this ECG pattern are at high risk if given medical treatment alone, and revascularization will often reverse both the T-wave inversion and wall-motion abnormalities 2

  • The chest pain episode 2 days prior followed by persistent T-wave inversions fits the classic Wellens' presentation: pain-free interval with persistent ECG changes indicating critical stenosis 3, 5

  • Wellens' syndrome can present with lesions in the mid-LAD (not just proximal), expanding the anatomical correlation 3

Why Other Options Are Less Likely

Takotsubo Syndrome (Option b)

  • Takotsubo typically presents with ST-segment elevation mimicking anterior STEMI during the acute phase, not isolated T-wave inversions 2 days post-symptom onset 6

  • The presence of chronic structural heart disease (bicuspid valve, aortic insufficiency) makes primary stress cardiomyopathy less likely than underlying structural disease

Evolving Pericarditis (Option c)

  • Pericarditis typically produces diffuse ST-segment elevation in multiple leads with PR depression, not focal anterior T-wave inversions 7

  • The pattern described (prominent T-wave inversions in specific leads) is inconsistent with the global, diffuse changes of pericarditis 6

CNS Pathology (Option d)

  • Central nervous system events (especially intracranial hemorrhage) can cause deep T-wave inversions with QT prolongation 7, 1

  • However, this diagnosis requires clinical evidence of neurological symptoms or signs, which are not mentioned in this case 1

  • CNS-related T-wave changes are typically accompanied by other clinical manifestations of intracranial pathology

Mandatory Urgent Diagnostic Algorithm

Given the life-threatening implications of Wellens' syndrome, the following immediate evaluation is required regardless of the suspected diagnosis:

Immediate Actions (Within 10 Minutes)

  1. Obtain serial cardiac biomarkers (high-sensitivity troponin) to distinguish NSTEMI from stable cardiomyopathy 7, 1

  2. Compare with any prior ECGs to determine if T-wave inversions are new or chronic 1, 2

  3. Measure serum potassium and electrolytes to exclude reversible metabolic causes 1

  4. Review medication list for tricyclic antidepressants or phenothiazines that can cause deep T-wave inversions 7, 1

Risk Stratification Based on Troponin Results

If troponin is elevated or rising:

  • Immediate cardiology consultation and urgent coronary angiography to exclude critical LAD stenosis (Wellens' syndrome) 1, 3, 5

  • Patients with Wellens' pattern and elevated troponin require revascularization, not medical management alone 2, 3

If troponin is normal and T-wave inversions are chronic (unchanged from prior ECGs):

  • Proceed with transthoracic echocardiography as first-line imaging to assess for apical hypertrophic cardiomyopathy, left ventricular hypertrophy, and wall motion abnormalities 1

  • If echocardiography is non-diagnostic, cardiac MRI with gadolinium is mandatory to detect subtle myocardial hypertrophy, fibrosis, or apical ballooning that may be missed on echo 1, 2

Specific Echocardiographic Findings to Assess

  • Left ventricular wall thickness, particularly apical segments (apical HCM shows predominant apical hypertrophy) 1

  • Regional wall motion abnormalities (anterior wall hypokinesis suggests LAD territory ischemia) 1, 2

  • Aortic valve morphology and severity of aortic insufficiency (may contribute to LV remodeling) 1

  • Left ventricular ejection fraction and overall systolic function 1

Critical Pitfalls to Avoid

  • Do not assume chronic structural heart disease explains new T-wave inversions without excluding acute coronary syndrome 1, 2

  • Do not rely on a single normal echocardiogram to exclude cardiomyopathy when lateral T-wave inversions ≥2 mm are present, as early-stage disease may be echo-occult 1

  • Do not dismiss the Wellens' pattern based solely on the presence of underlying structural heart disease—these patients can have concurrent critical coronary stenosis 3, 4

  • Patients with left ventricular hypertrophy and ST-T wave changes represent the highest risk group for adverse outcomes, even higher than those with primary ST deviation 6

Definitive Answer

While apical hypertrophic cardiomyopathy (option e) is the most likely diagnosis given the chronic structural heart disease context, the clinical scenario demands urgent exclusion of Wellens' syndrome (option a) through serial troponins and comparison with prior ECGs. The presence of chest pain 2 days prior with persistent anterior T-wave inversions creates diagnostic ambiguity that can only be resolved through immediate cardiac biomarker testing and imaging. If this represents new T-wave inversion with any troponin elevation, urgent coronary angiography is mandatory to prevent impending anterior wall myocardial infarction. 1, 2, 3, 5

References

1
Guideline

Global T-Wave Inversion on ECG: Clinical Significance and Diagnostic Approach

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

T-Wave Inversion in Chronic Coronary Syndrome

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

6
Guideline

Non-Myocardial Infarction Causes of ST Changes on ECG

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

7
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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