FLIPPED T WAVES

Question 1

DDX

Answer 1

CRITICAL
Brugada
SAH
Wellen’s
Arrythmogenic Right Ventricular Dysplasia (ARVD)
MI
Myocarditis / Pericarditis
PE

OTHER
Hypokalemia
Persistent Juvenile T-wave pattern

Question 2

BRUGADA

Answer 2

RSR’ with coved ST
V1-V3

Question 3

SAH / RAISED ICP

Answer 3

Widespread giant T-wave inversions (“cerebral T waves)
QT prolongation
Brady cardia (Cushing’s reflex)

Less Common:
ST segment elevation / depression
Increased U wave amplitude

Question 4

WELLEN’s

Answer 4

Type B (75%) - Inverted t wave in V2-3 (may extend to V1-6)

OR

Type A (25%) - Biphasic t wave pattern (initial positivity, terminally negative) in V2-3 (may extend to V1-6)

PLUS

ECG pattern is present in a pain free state

May evolve from a Type A to Type B over time.

A recent history of chest pain (resolved)

Signifies a Critical LAD occlusion

Inverted T waves are a marker of reperfusion and may occur after an aborted anterior STEMI

Patient’s may be pain free and with minimally elevated or normal cardiac enzymes

patients are at risk of sudden LAD re-occlusion leading to massive anterior STEMI, require invasive therapy

Re-occlusion of the LAD will lead to normalization of the t waves (“pseudo-normalization”) and evolve into a STEMI

Question 5

PULMONARY EMBOLISM

Answer 5

1) Sinus Tachycardia
2) Right Axis Deviation
3) Incomplete or complete RBBB
4) Right Ventricular Strain Pattern:
T wave inversion inferior and anteroseptal leads
5) S1, Q3, T3 Pattern:
Large S wave in lead I
Small Q wave in lead III
Inverted T wave in lead III

Question 6

HYPOKALEMIA

Answer 6

Prominent U waves (best seen in the precordial leads V2-V3)

Apparent long QT interval due to fusion of T and U waves (= long QU interval)

Increased P wave amplitude

Prolongation of PR interval

Widespread ST depression and T wave flattening/inversion

Question 7

PERSISTENT JUVENILE T-WAVE PATTERN

Answer 7

T-wave inversions in leads V1−V3
T-wave inversions are asymmetric and shallow