Is T wave inversion in lead V2 normal?

From the Guidelines

T wave inversion in lead V2 is not typically normal in adults and may indicate an underlying cardiac issue, but it can be a normal variant in certain populations, such as Black individuals or those with a juvenile T wave pattern. According to the most recent and highest quality study 1, T wave inversion in the anterior leads, including V2, may be associated with arrhythmogenic right ventricular cardiomyopathy (ARVC) or other cardiac conditions. The study recommends echocardiography as a routine diagnostic test for this ECG phenotype, and consideration of cardiac magnetic resonance (CMR) imaging if available. Some key points to consider when evaluating T wave inversion in V2 include:

• The patient's age, as T wave inversion can be a normal finding in children and adolescents
• The presence of other ECG abnormalities or symptoms, such as chest pain or shortness of breath
• The patient's medical history and risk factors for heart disease
• The need for further evaluation, including additional ECG monitoring, echocardiography, or consultation with a cardiologist, to determine the underlying cause of the T wave inversion. As noted in the study 1, T wave inversion in leads V2–V4 is commonly observed in healthy athletes of African/Caribbean origin, and represents adaptive early repolarization changes which normalize during exercise or adrenergic stimulation. However, further evaluation is recommended to exclude an underlying cardiomyopathy or other cardiac condition, especially if the T wave inversion is persistent or accompanied by other symptoms or ECG abnormalities.

From the Research

T Wave Inversion in V2

• T wave inversion (TWI) in lead V2 can be a normal finding in certain individuals, as evidenced by studies that suggest TWI in the inferior lead group, which includes lead V2, is a benign phenomenon 2.
• A study published in the Annals of Noninvasive Electrocardiology found that T-wave inversion in the inferior lead group was not associated with an increased risk of coronary heart disease (CHD) or mortality 2.
• Another study published in the American Journal of Emergency Medicine noted that prominent, deeply inverted, and widely splayed T waves are more characteristic of non-ACS conditions, such as juvenile T-wave patterns, left ventricular hypertrophy, and acute myocarditis 3.
• However, it is essential to consider the clinical context and other ECG findings to determine the significance of TWI in lead V2, as TWI can also be associated with myocardial ischemia or other cardiac conditions 4, 5, 6.

Differential Diagnosis

• The differential diagnosis for TWI in lead V2 includes:
  • Myocardial ischemia or infarction
  • Left ventricular hypertrophy
  • Acute myocarditis
  • Wolff-Parkinson-White syndrome
  • Acute pulmonary embolism
  • Cerebrovascular accident
  • Bundle branch block
  • Pericarditis
  • Cardiac memory phenomenon 4, 3
  • Respiratory variation in T-wave morphology 5

Clinical Significance

• The clinical significance of TWI in lead V2 depends on the underlying cause and the presence of other ECG abnormalities or clinical symptoms.
• A study published in Cureus found that TWI sum in anterior leads, including lead V2, can be used to differentiate between acute coronary syndrome and pulmonary embolism 6.
• However, the prognostic significance of TWI in lead V2 is generally considered to be low, as it is not associated with an increased risk of CHD or mortality in the general population 2.