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7/14/13 T wave ECG Basics

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T Wave
The T wave is the positive deflection after each QRS complex.

It represents ventricular repolarisation.

Characteristics Of The Normal T Wave

Upright in all leads except aVR and V1


Amplitude < 5mm in limb leads, < 15mm in precordial leads

Duration (see QT interval)

T Wave Abnormalities

Hyperacute T waves
Inverted T waves

Biphasic T waves
Camel Hump T waves

Flattened T waves

Peaked T Waves

Tall, narrow, symmetrically peaked T-waves are characteristically seen in hyperkalaemia.

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7/14/13 T wave ECG Basics

Pe ake d T wave s due to hype rkalae mia

Hyperacute T Waves

Broad, asymmetrically peaked or hyperacute T-waves are seen in the early stages of ST-elevation MI (STEMI) and often precede
the appearance of ST elevation and Q waves. They are also seen with Prinzmetal angina.

Hype racute T wave s due to ante rior STEMI

Loss of precordial T-w ave balance

Loss of precordial T-wave imbalance occurs when the upright T wave is larger than that in V6. This is a type of hyperacute T wave.

The normal T wave in V1 is inverted. An upright T wave in V1 is considered abnormal especially if it is tall (TTV1), and
especially if it is new (NTTV1).
This finding indicates a high likelihood of coronary artery disease, and when new implies acute ischemia.

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Inverted T Waves

Inverted T waves are seen in the following conditions:

Normal finding in children


Persistent juvenile T wave pattern

Myocardial ischaemia and infarction


Bundle branch block
Ventricular hypertrophy (strain patterns)
Pulmonary embolism

Hypertrophic cardiomyopathy
Raised intracranial pressure

T wave inversion in lead III is a normal variant. New T-wave inversion (compared with prior ECGs) is always abnormal. Pathological T wave
inversion is usually symmetrical and deep (>3mm).

Paediatric T Waves

Inverted T-waves in the right precordial leads (V1-3) are a normal finding in children, representing the dominance of right
ventricular forces.

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7/14/13 T wave ECG Basics

Normal patte rn of T-wave inve rsions in a 2-ye ar old boy

Persistent Juvenile T-Wave Pattern

T-wave inversions in the right precordial leads may persist into adulthood and are most commonly seen in young Afro-
Caribbean women. Persistent juvenile T-waves are asymmetric, shallow (<3mm) and usually limited to leads V1-3.

Pe rsiste nt juve nile T-wave s in an adult

Myocardial Ischaemia And Infarction

T-wave inversions due to myocardial ischaemia or infarction occur in contiguous leads based on the anatomical location of the area of
ischaemia/infarction:

Inferior = II, III, aVF


Lateral = I, aVL, V5-6

Anterior = V2-6

NOTE:

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Dynamic T-wave inversions are seen with acute myocardial ischaemia.

Fixed T-wave inversions are seen following infarction, usually in association with pathological Q waves.

Infe rior T wave inve rsion due to acute ischae mia

Infe rior T wave inve rsion with Q wave s due to prior infe rior MI

T wave inve rsion in the late ral le ads due to acute ischae mia

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7/14/13 T wave ECG Basics

Ante rior T wave inve rsion with Q wave s due to re ce nt ante rior MI

Bundle Branch Block

Left Bundle Branch Block

Left bundle branch block produces T-wave inversion in the lateral leads I, aVL and V5-6.

Late ral T wave inve rsion due to LBBB

Right Bundle Branch Block

Right bundle branch block produces T-wave inversion in the right precordial leads V1-3.

T-wave inve rsion in the right pre cordial le ads due to RBBB

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7/14/13 T wave ECG Basics

Ventricular Hypertrophy

Left Ventricular Hypertrophy

Left ventricular hypertrophy produces T-wave inversion in the lateral leads I, aVL, V5-6 (left ventricular strain pattern), with a
similar morphology to that seen in LBBB.

Late ral T wave inve rsion due to LVH

Right Ventricular Hypertrophy

Right ventricular hypertrophy produces T-wave inversion in the right precordial leads V1-3 (right ventricular strain pattern)
and also the inferior leads (II, III, aVF).

T wave inve rsion in the infe rior and right pre cordial le ads due to RVH

Pulmonary Embolism

Acute right heart strain (e.g. secondary to massive pulmonary embolism) produces a similar pattern to RVH, with T-wave
inversions in the right precordial (V1-3) and inferior (II, III, aVF) leads.

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T wave inve rsion in the infe rior and right pre cordial le ads in a patie nt with bilate ral PEs

De e p T wave inve rsion in V1-3 with RBBB in a patie nt with massive PE

Pulmonary embolism may also produce T-wave inversion in lead III as part of the SI QIII TIII pattern (S wave in lead I, Q wave in

lead III, T-wave inversion in lead III).

SI QIII TIII patte rn in acute PE

Hypertrophic Cardiomyopathy (HOCM)

HOCM is associated with deep T wave inversions in all the precordial leads.

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T wave inve rsion in V1-6 due to HOCM

Raised Intracranial Pressure

Events causing a sudden rise in ICP (e.g. subarachnoid haemorrhage) produce widespread deep T-wave inversions with a bizarre
morphology.

Wide spre ad de e p T wave inve rsion due to SAH

Biphasic T Waves

There are two main causes of biphasic T waves:

Myocardial ischaemia

Hypokalaemia

The two waves go in opposite directions:

Ischaemic T waves go up then down

Hypokalaemic T waves go down then up

Ischaemia

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Biphasic T wave s due to ischae mia

Hypokalaemia

Biphasic T wave s due to hypokalae mia

Wellens Syndrome

Wellens syndrome is a pattern of inverted or biphasic T waves in V2-3 (in patients presenting with ischaemic chest pain) that is highly
specific for critical stenosis of the left anterior descending artery.

There are two patterns of T-wave abnormality in Wellens syndrome:

Type 1 Wellens T-waves are deeply and symmetrically inverted

Type 2 Wellens T-waves are biphasic, with the initial deflection positive and the terminal deflection negative

Wellens Type 1

Wellens Type 2

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Camel Hump T Waves

This is a term used by the great ECG lecturer and Emergency Physician Amal Mattu to describe T-waves that have a double peak or camel
hump appearance.

There are two causes for camel hump T waves:

Prominent U w aves fused to the end of the T wave, as seen in severe hypokalaemia

Hidden P w aves embedded in the T wave, as seen in sinus tachycardia and various types of heart block

Promine nt U wave s due to se ve re hypokalae mia

Hidde n P wave s in sinus tachycardia

Hidde n P wave s in marke d 1st de gre e he art block

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Hidde n P wave s in 2nd de gre e he art block with 2:1 conduction

Flattened T Waves

Flattened T waves are a non-specific finding, but may represent ischaemia (if dynamic or in contiguous leads) or electrolyte
abnormality, e.g. hypokalaemia (if generalised).

Ischaemia

Dynamic T-wave flattening due to anterior ischaemia (above). T waves return to normal once the ischaemia resolves (below).

Dynamic T wave flatte ning due to ante rior ischae mia

T wave s re turn to normal as ischae mia re solve s

Hypokalaemia

Note generalised T-wave flattening with prominent U waves in the anterior leads (V2 and V3).

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T wave flatte ning due to hypokalae mia

Related Topics

P wave
Q wave

R wave

Further Reading

ECG BASICS Waves, Intervals, Segments and Clinical Interpretation

ECG CLINICAL CASES Your favourite ECGs placed in clinical context with a challenging Q&A approach
ECG and Cardiology Eponymous Syndromes Cheats guide to eponymous emancipation
ECG Exam Template a framework for the FACEM part 2 exam.

ECG Reference Sites on the WEB the best of the rest

Author Credits

Words - Ed Burns

Pictures - Ed Burns
Web Editing - Ed Burns

References

Surawicz B, Knilans TK. Chous Electrocardiography in Clinical Practice. 6th Edition. Saunders Elsevier 2008.
Wagner, GS. Marriotts Practical Electrocardiography (11th edition), Lippincott Williams & Wilkins 2007.

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About Edw ard Burns


Ed Burns is an Emergency Medicine Registrar, originally from England, but now based in Western Australia. A self-
described ECG nerd, Ed is the force behind the ECG library and ECG Exigency series - Read Posts + Edward Burns |
Contact

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