What is the significance and recommended management of an isolated peaked T wave in lead V2?

Peaked T Wave Isolated to Lead V2

An isolated peaked T wave in lead V2 is a normal variant in healthy individuals and does not require further cardiac evaluation in asymptomatic patients without cardiovascular risk factors or family history of cardiac disease. 1

Normal Physiological Context

• Tall, peaked T waves in the precordial leads (including V2) are common training-related findings in athletes and represent normal repolarization patterns that do not warrant additional investigation 1
• Early repolarization with J-point elevation and tall, peaked T waves in leads V2-V4 is considered a normal variant, particularly in young individuals and athletes 1
• The most common morphological pattern in healthy individuals is an elevated ST-segment with upward concavity ending in a positive, peaked, and tall T-wave 1

When to Investigate Further

Evaluate comprehensively if any of the following features are present:

• Extension beyond V2: T-wave abnormalities (inversion or excessive peaking) extending to V3 or beyond require echocardiography to exclude arrhythmogenic right ventricular cardiomyopathy (ARVC) or hypertrophic cardiomyopathy 1
• Associated symptoms: Chest pain, dyspnea, palpitations, syncope, or family history of sudden cardiac death mandate full cardiac workup 2, 3
• T-wave inversion rather than peaking: If the T wave in V2 is inverted (not peaked), this may represent early ARVC in post-pubertal individuals, occurring in <1.5% of healthy people 3, 4
• Dynamic changes: New appearance or changes in T-wave morphology compared to prior ECGs suggests active pathology 4

Age-Specific Considerations

• In adolescents <16 years, T-wave changes (including inversions) confined to V1-V3 represent the normal "juvenile pattern" and do not require evaluation in asymptomatic individuals 1
• In Black/African-Caribbean athletes, J-point elevation with convex ST-segment elevation followed by T-wave changes in V2-V4 is a recognized normal variant 1

Common Pitfalls to Avoid

• Do not confuse peaked T waves with T-wave inversion: Peaked (tall, positive) T waves in V2 are benign, whereas inverted T waves warrant investigation 3, 4
• Do not dismiss if accompanied by other ECG abnormalities: Isolated peaked T waves are benign, but when combined with pathological Q waves, ST-segment depression, or conduction abnormalities, comprehensive evaluation is required 2, 3
• Verify proper lead placement: Ensure V2 electrode is correctly positioned at the 4th intercostal space, left sternal border, as lead misplacement can create pseudo-abnormal patterns 4

Clinical Algorithm

For an isolated peaked T wave in V2:

1. Confirm the finding is truly isolated (no other ECG abnormalities, no extension to V3 or other leads) 1
2. Obtain focused history: Cardiac symptoms, family history of sudden cardiac death or cardiomyopathy, and cardiovascular risk factors 2, 3
3. If asymptomatic with no risk factors: Reassure patient—this is a normal variant requiring no further workup 1
4. If symptomatic or risk factors present: Proceed with echocardiography, cardiac biomarkers, and cardiology consultation 2, 3