Syncope with QT-interval prolongation and T-wave inversion in anterior and inferior leads: Foreboder of a life-threatening condition?

Even though patients with pulmonary embolism usually present with respiratory distress and tachycardia, the patient presented with syncope only. Typical ECG changes associated with PE include right axis deviation, right bundle-branch block, S1Q3T3 pattern, arrhythmia, nonspecific ST-segment changes, QR pattern in lead V1, Brugada ECG pattern, and T-wave inversions in the precordial leads. However, his electrocardiogram showed QT-interval prolongation and simultaneous T-wave inversions in the inferior and anterior leads. This ECG pattern is crucial for diagnosing PE. The patient underwent computed tomography-pulmonary angiography, which revealed pulmonary embolism. At the same time, these ECG changes should be differentiated from those of long QT syndrome, myocardial ischemia, Takotsubo cardiomyopathy, post-pacing T-wave memory, hypertrophic cardiomyopathy, and subarachnoid hemorrhage.

Utility of Exercise Stress Testing in Pediatric Patients with T-Wave Inversions.

T-wave inversions (TWI) in inferolateral electrocardiogram (ECG) leads (II, III, aVF, V5-V6) are often suggestive of cardiac pathology in adult patients. They are a common reason of additional testing in pediatric patients. The goal of the study is to determine correlation of exercise stress test T-wave response with diagnosis of cardiac pathology. This is a retrospective review of pediatric patients < 21 years with the finding of baseline TWI in inferior (II, III, avF) and/or lateral (V5-V6) leads on 12-lead ECG. All patients underwent treadmill exercise stress test (EST) and an echocardiogram within 1 year of each other. Demographics, baseline ECG findings, echocardiogram results, and EST data were recorded. T-wave reversion was considered complete if T waves demonstrated normalization during exercise, partial if there was minimal improvement, and no response if there was no change or worsening of inversions. In our cohort of 72 patients with a mean age 14.6 (± 2.9) years and 61% males, 59 (82%) had a structurally normal heart. Thirteen patients had evidence of structural or functional heart disease. Of the 59 patients, 83% had either complete or partial T-wave response. Among the 13 patients with heart disease, two patients had genetic testing consistent with risk for hypertrophic cardiomyopathy and had complete and partial response on EST. Exercise stress testing for TWI in pediatric patients has low sensitivity and specificity for the diagnosis of cardiac disease and routine use in this patient population may not be indicated.

Dynamic T-Wave Inversion: Unraveling an Athlete's Heart Mystery.

A 17-year-old athlete was initially diagnosed with presumed hypertrophic cardiomyopathy, marked by deep inferolateral T-wave inversions and mild anteroseptal hypertrophy on electrocardiogram and imaging studies. Remarkably, 6 years later, following detraining, all diagnostic signs completely resolved. This case underscores the significance of vigilant athlete follow-up.

An Unexpected Case of Severe Arrhythmogenic Right Ventricular Cardiomyopathy.

We present the case of a previously healthy 14-year-old boy who experienced two episodes of lightheadedness while sitting under the sun. The patient did not experience syncope and denied experiencing any other symptoms. Moreover, he exhibited great functional capacity. An electrocardiogram showed T-wave inversions in leads V1 to V4. Subsequent echocardiogram and cardiac magnetic resonance imaging confirmed the diagnosis of arrhythmogenic cardiomyopathy with severe features. Arrhythmogenic cardiomyopathy is a disorder characterized by fibrofatty degeneration of the myocardium and is a common cause of sudden cardiac death. This case highlights the significance of early investigation in any child who presents with seemingly benign symptoms, as they may be indicative of a serious cardiac disease.

Global T-wave inversions with isolated hypomagnesemia.

BACKGROUND: The physiological actions of magnesium within the cardiac conduction system and myocytes have yet to be fully elucidated. Because concurrent hypocalcemia or hypokalemia were also present in previous human reports, specific electrocardiographic effects of isolated hypomagnesemia have not been clearly delineated. OBJECTIVE: We report a case in which dynamic electrocardiogram (ECG) changes were demonstrated in isolated hypomagnesemia. CASE REPORT: A 37-year-old man with history of heavy alcohol use was admitted for syncope. The ECG showed global T-wave inversions with prolonged corrected QT (QTc) duration on ECG. Extensive work-up including cardiac catheterization was unremarkable. His serum magnesium was noted to be low at 1.1 mg/dL, and his serum calcium and potassium were within normal limits. The patient received magnesium infusion with subsequent ECGs showing resolution of his global T-wave inversions and prolonged QTc. CONCLUSION: This case is unique because it reports dynamic ECG changes in a patient with isolated hypomagnesemia. Although isolated hypomagnesemia is commonly believed to result in dysrhythmia, we were unaware of any previous cases of ECG abnormalities in humans. Clinically, we advise checking serum magnesium and correcting hypomagnesemia when prolonged QTc duration and global T-wave inversions are seen on ECG.

T-Wave Inversion After Escitalopram Overdose: A Case Report.

Selective serotonin reuptake inhibitors (SSRIs) are the most common antidepressants used due to their comparatively less cardiotoxic effects than tricyclic antidepressants. Corrected QT interval (QTc) prolongation is the most common electrocardiography (ECG) change that has been encountered with SSRI overdose. This case report is about a 22-year-old woman who was brought to the emergency department (ED) with an alleged history of consumption of 200 mg of escitalopram. Her ECG showed T-wave inversions in anterior leads one to five, which reverted (in leads four and five) the next day with supportive management. After 24 hours, she developed dystonia, which resolved with mild doses of benzodiazepine. Hence, ECG changes like T-wave inversions may occur even with a small overdose of an SSRI without any significant adverse effects.

Absence of ST-Segment Elevation in Inferior and Lateral Leads in Patients With Complete Right Bundle Branch Block Is an Index of Underlying Cardiac Pathology.

A recent report called attention to the nature of the ST-segment elevation (STSE) in some or all inferior and/or lateral electrocardiogram (ECG) leads (i.e., I, II, III, aVL, aVF, V5, and V6), which are frequently encountered in patients with stable or transient complete right bundle branch block (RBBB). These STSEs represent secondary repolarization changes due to late depolarization RBBB alterations; are stable over the course of many years in patients with RBBB; and do not reflect cardiac pathology, as the automated ECG interpretation algorithms erroneously indicate. Indeed, the absence of such STSEs in patients with RBBB suggests the presence of underlying acute or old myocardial infarction, acute myocardial ischemia, or left ventricular hypertrophy and thus constitute an as yet undescribed ECG index of cardiovascular pathology.

Critical Stenosis in Left Anterior Descending Artery: Beware of T- Wave Inversions.

Wellens' syndrome (WS) is a pattern on an electrocardiogram (ECG) characterized by biphasic T waves or deeply inverted T waves in leads V2-V3 with a recent clinical history of angina. Wellens' pattern on the ECG is particular for critical left anterior descending artery (LAD) stenosis. Wellens' sign and WS have been used interchangeably in the literature. However, the typical patterns of ECG changes noted are mostly represented by Wellens' sign. These ECG changes have been crucial in identifying this subset of patients with severe LAD disease.

Reversible T-wave inversions during left bundle branch area pacing.

BACKGROUND: Our clinical observation found that T-wave inversions (TWIs) appeared during left bundle branch area pacing (LBBAP); however, the incidence and influencing factors were unclear. The study aimed to investigate the effects of LBBAP on T-wave and explore possible factors associated with TWIs. METHODS: This was a retrospective cohort study. An electrocardiogram (ECG) was acquired at baseline and after LBBAP. Baseline characteristics, ECG parameters, LBBAP parameters, and troponin T (TnT) levels were compared between the non-TWIs and TWIs groups. Multivariable logistic analyses were performed to adjust for potential confounders to identify the predictive factors of TWIs during LBBAP. RESULTS: A total of 398 consecutive patients who underwent successful LBBAP were assessed for inclusion between May 2017 and Jan 2021, and 264 (66.3%) patients had TWIs. The mean (standard deviation [SD]) baseline QRS duration (QRSd) was longer in the TWIs group compared to the non-TWIs group (125.9 [34.5] ms vs. 98.2 [18.1] ms; P <0.001). Multivariable logistic regression analysis suggested that QRSd >120 ms was an independent predictor for TWIs. TWIs were partially or com-pletely recovered in 151/172 (87.8%) patients during follow-up, the median (interquartile range [IQR]) follow-up duration was 10 days (7 days to 5.5 months). TWIs in patients with complete left bundle branch block (CLBBB) occurred more frequently in inferior wall leads (II, III, and aVF) and anterior wall leads (V1-V4) (P <0.05). Patients with complete right bundle branch block (CRBBB) were more prone to TWIs in high lateral wall leads (I and aVL) (P <0.05). There were no significant differences in TnT levels between the TWIs and non-TWIs groups. CONCLUSIONS: TWIs during LBBAP were clinically frequent and recoverable. QRSd >120 ms was independently associated with TWIs.

Outcomes in ED patients with non-specific ECG findings and low high-sensitivity troponin.

Background: Although some emergency department risk stratification tools consider non-specific ECG findings as an aid in disposition decisions, their clinical value in patients with an initially low high-sensitivity cardiac troponin I (hsTnI) is unclear. Objective: Our purpose was to determine if non-specific ECG (ns-ECG) findings are associated with 30-day major adverse cardiac events (MACE) in ED patients presenting with suspected acute coronary syndromes (ACS) who have a low initial hsTnI. Methods: Using the prospective Siemens Atellica hsTnI Food and Drug Administration submission observational database, we conducted a retrospective cohort study of the association between ns-ECG findings (defined as left bundle branch block [LBBB], ST depression [STD], or T-wave inversions [TWI]) and 30-day MACE (death, myocardial infarction, heart failure hospitalization, or coronary revascularization). Eligible patients presented with suspected ACS to one of 29 US EDs from April 2015 to April 2016, had stable vital signs, a blood sample for hsTnI (Siemen's Atellica, Siemens Healthineers, Inc, Malvern, PA) obtained at 1, 3, and 6 hours after ED presentation, and were followed for 30 days. The relationship between 30-day outcome, initial hsTnI, and ns-ECG was evaluated using chi-square testing. Results: Of 2676 enrolled, 1313 patients met the inclusion criteria and are included in the analysis. Median (interquartile range) age was 62 years (54, 72), 54% were male, with 56% white, and 39% African American. Median (interquartile range) times from symptom onset to presentation and presentation to specimen collection were 92 (0, 216) and 146 (117, 177) minutes, respectively. The most common presenting symptoms were chest pain (84%), followed by dyspnea (9%). ECG findings were categorized as T-wave inversion or non-specific T wave changes (42%), ST depression ns-ECG ST changes (16%), or LBBB (2%). Thirty-day MACE occurred in 72 (5.5%) patients, with coronary revascularization (35 patients, 2.7%) and heart failure (25 patients, 1.9%) being the most frequent outcomes. In patients with an initial hsTnI below the limit of quantitation (LOQ) of 2.5 ng/L (n = 449), there was no association between ns-ECG changes and 30-day MACE (P = 0.42). If the hsTnI was ≥LOQ (2.5 ng/L), there were increased rates of 30-day MACE and ns-ECG findings (P = 0.01). Conclusion: In ED suspected ACS patients without unstable vital signs, and an initial hsTnI less than the LOQ (2.5 ng/L), ns-ECG findings are not associated with 30-day major adverse cardiac events. The use of ns-ECG findings in ACS disposition should be considered in the context of hsTnI levels.

An idiopathic case of precordial deep T-wave inversion.

INTRODUCTION AND IMPORTANCE: One percent of the patients referred to cardiac intensive care unit (CICU) are presented with T-wave inversion. CASE PRESENTATION: We present a case of 78-year-old woman with chest pain and dyspnea. ECG showed precordial deep T-wave inversion. CLINICAL DISCUSSION: Cardiomyopathies, ischemia and other pathologies were ruled out. CONCLUSION: It is likely to be a first reported case of idiopathic deep T-wave inversion seen in the family without any cardiac or non-cardiac etiology.

Cardiac Memory-induced T-wave Inversions.

INTRODUCTION: Cardiac memory refers to T-wave inversions that result when normal ventricular activation resumes following a period of abnormal ventricular activation. CASE REPORT: We present a case of a 29-year-old man with a pacemaker who presented with new, deep symmetric T-wave inversions caused by cardiac memory. DISCUSSION: Abnormal ventricular activation is most commonly induced by ventricular pacing but can also occur in the setting of transient left bundle branch blocks, ventricular tachycardia, and intermittent ventricular pre-excitation. CONCLUSION: Recognition of this phenomenon may help to reduce unnecessary admissions, cardiac testing, and cardiac catheterizations.

A Case of Wellens Syndrome in a 30-Year-Old Woman From Sub-Saharan Africa: A Perplexing Clinical Entity With Invaluable Lessons.

With an estimated contribution of up to 6% of all acute coronary events, young adults are experiencing an escalating burden and mortality attributable to coronary artery disease (CAD) worldwide. Wellens syndrome, a preinfarction clinical entity with distinctive electrocardiographic (ECG) features and high propensity for extensive anterior wall infarctions, affects about 15% of unstable angina subpopulation. We report challenges and lessons learnt from the first ever documented case of Wellens syndrome in Tanzania. A 30-year-old female of African descent was referred to us from an upcountry zonal referral hospital for etiological determination of chest pain and expert management. Her medical history was unremarkable, and she had no apparent risk factors for CAD. She presented with a 7-day history of ongoing sharp central chest pain that was radiating to the neck and jaws and relieved momentarily by morphine. She had stable vitals with an unremarkable systemic examination; however, a 12-lead ECG revealed deeply inverted T-waves on leads V2 through V4. Based on our extensive history and physical examination we came up with a diagnosis of type B Wellens syndrome with impending anterior wall myocardial infarction. She underwent cardiac catheterization that revealed a nonthrombogenic severe subocclusive (>95%) mid left anterior descending artery stenosis. Subsequently, angioplasty was performed successfully with a resolute integrity stent, and TIMI III flow was achieved. To conclude, despite its relative frequency, physicians' awareness of Wellens syndrome pathognomonic ECG features is of paramount importance to curb its attributable morbidity and mortality.

[Cardiac memory following pacemaker implantation]. / Cardiac Memory nach Schrittmacherimplantation.

BACKGROUND: Although T wave inversions due to cardiac memory were described already 50 years ago, little is known about the prevalence and about clinical predictors of this phenomenon. METHODS: After exclusion of 238 patients due to bundle branch block or pacemaker dependency, a total of 325 consecutive patients were enrolled in this study during routine outpatient control of their pacemaker. A 12-lead standard ECG was obtained in all patients during transient inhibition of pacing therapy. RESULTS: Cardiac memory could be documented in 115 of 325 patients (35%) and showed a strong association with the amount of ventricular stimulation. The prevalence of cardiac memory was 9% in patients with ≤25% ventricular stimulation and 86% in patients with ≥75% ventricular stimulation. DISCUSSION: Cardiac memory was observed in one third of patients following pacemaker implantation. The prevalence of cardiac memory in the ECG with intrinsic rhythm is above 80% in patients with frequent ventricular stimulation. Cardiac memory due to ventricular stimulation is benign and should not be confused with similar T wave inversions due to acute coronary syndrome, severe left ventricular hypertrophy, or myocarditis.