Thursday, 12 May 2016

Giant T waves

48 year old male who fell while intoxicated, patient was also complaining of right-sided chest pain on arrival of the emergency services.


Past medical history: Polio, Liver carcinoma, Pulmonary hypertension, patient is also alcohol dependent, and he has had numerous attendances at the Emergency Department (ED) regarding alcohol issues and chest pain over the last few months. On this occasion the patient was admitted to a cardiology ward for further investigations because his ECG showed widespread global diffuse T-wave inversion. The patient had a echo the following day after admission, the results showed Right-sided right ventricular enlargement.

Inverted T waves are frequently seen in electrocardiograms (ECGs) and may represent a myriad of pathologies or nonspecific change. However, deep (giant) inverted T waves are only seen in a few clinical conditions. Presence of giant T waves should generally prompt investigations for apical (Yamaguchi) variant of hypertrophic cardiomyopathy, raised intracranial pressure, severe myocardial ischemia, post tachycardia syndrome, and a few other conditions. 

What is Global (Diffuse) T-wave inversion?

• T wave is inverted in most of the standard leads except aVR, which shows a reciprocal upright T wave.
• The QT interval is often prolonged, and T-wave inversion is often symmetric and “giant” >10 mm, i.e, 2 big boxes).
• This is different from Wellens T waves, wherein the T abnormality is limited to the anterior leads (especially V2-V4) and ST segment is slightly upsloping.

Most common causes of Global T-wave inversion

1) Myocardial ischemia
2) Intracranial hemorrhage or any intracranial process
3) Hypertrophic cardiomyopathy
4) High catecholamine states: cocaine use, pheochromocytoma, Takotsubo (stress-induced) cardiomyopathy
5-Other: pericarditis or myocarditis, high-grade AV block, Pulmonary Embolism.

Figure 1: This is the patient's ECG that was recorded two months prior to this hospital admission, what abnormalities do you see?

Figure 2: ECG shows widespread diffused T wave inversion. Giant T wave inversion can be broad and deep or just deep T inversions. A depth of T wave of >10 mm or above is generally considered as deep T inversion 

Figure 3: Illustrated copy of above ECG, shows the pre-hospital ECG recorded by paramedics on scene in the patient own home.

Figure 4: This 12-lead ECG was recorded by the Emergency Department staff on the day of admission.
Figure 5: Shows long rhythm strip recorded 

Figure 6: This study card of giant T-wave inversion is for you to save as a memo aid, save the image to your electronic devices for future reference.

This is a interesting case I have NOT seen that often, if you have any interesting ECG's like this in your collection, that you would like to share with others, then please send them to me at: ECG.EDUCATOR@GMAIL.COM

References and further reading: