From the Guidelines
T wave sagging, also known as T wave inversion, is a significant finding that warrants further clinical evaluation to exclude underlying cardiomyopathy or other cardiac diseases, as recommended by the European Heart Journal in 2010 1.
Clinical Significance
T wave inversion is rarely observed in healthy athletes, but it is a common finding in patients with cardiomyopathy and other cardiac diseases. The presence of T wave inversion, especially in leads other than V1, requires a comprehensive clinical work-up, including family evaluation and mutation analysis, to exclude inherited forms of cardiovascular disease.
Diagnostic Approach
In athletes with T wave inversion, further clinical and echocardiographic evaluation is necessary to exclude underlying cardiomyopathy, such as arrhythmogenic right ventricular cardiomyopathy (ARVC) or hypertrophic cardiomyopathy (HCM) 1. Additionally, serial ECG and echocardiography evaluations are recommended to monitor for potential development of structural heart disease.
Ethnic Considerations
In healthy athletes of African/Caribbean origin, T wave inversion in leads V2-V4 is commonly observed and may represent adaptive early repolarization changes. However, T wave inversion in inferior and/or lateral leads is uncommon and warrants further investigation to exclude underlying heart disease.
Management
The management of T wave sagging depends on the underlying cause. If the cause is related to electrolyte disturbances, such as hypokalemia, potassium supplementation may be necessary. If the cause is related to cardiac ischemia, further cardiac workup, including cardiac enzymes, stress testing, or coronary angiography, may be indicated. Prompt identification and treatment of the underlying cause is crucial to prevent potential cardiac complications.
From the Research
T Wave Sagging
- T wave abnormalities are common electrocardiographic occurrences in patients with non-ST-segment elevation acute coronary syndromes, and are not considered benign phenomena 2
- The prognostic significance of T-wave inversion may differ between different anatomical lead groups, with anterior and lateral T-wave inversions associated with increased risk of coronary heart disease (CHD) and mortality 3
- T-wave heterogeneity (TWH) can identify patients who are at risk for near-term cardiac mortality, particularly in women, with elevated TWHV4-6 associated with near-term cardiac mortality 4
- Primary T waves are characterized by symmetrical waves with broad bases and variable QT intervals, indicative of direct myocardial action potential modifications due to ischemia, electrolyte imbalances, and channelopathies 5
- Secondary T waves are asymmetric and often unassociated with significant QT interval changes, suggesting depolarization alterations or changes in cardiac geometry and contractility 5
Causes of T Wave Abnormalities
- The causes of abnormal T waves on electrocardiography are multiple and varied, including ischemia, electrolyte imbalances, and channelopathies 6, 5
- Careful clinical history taking and physical examination are necessary for accurate identification of the cause of T wave abnormalities, with subsequent targeted specialized cardiac investigations, such as echocardiography or coronary angiography, may be of importance in the diagnosis of the underlying cardiac pathology 6
Clinical Implications
- T-wave abnormalities in patients presenting with non-ST-segment elevation acute coronary syndromes are common and should not automatically be regarded as benign phenomena, with quantitative T-wave analysis providing optimal risk stratification 2
- The prognostic information of inverted T waves differs between anatomical lead groups, with T-wave inversion in the anterior and lateral lead groups independently associated with the risk of CHD, and lateral T-wave inversion also associated with increased risk of mortality 3