Characteristics of the normal T wave
T wave abnormalities
Peaked T waves
Tall, narrow, symmetrically peaked T-waves are characteristically seen
Peaked T waves due to hyperkalaemia
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.
Hyperacute T waves due to anterior STEMI
precordial T-wave balance
Loss of precordial T-wave balance occurs when the upright T wave is
larger than that in V6. This is a type of hyperacute T wave.
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).
finding indicates a high likelihood of coronary artery disease, and
when new implies acute ischemia.
Inverted T waves
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
Normal pattern of T-wave inversions in a 2-year 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.
Persistent juvenile T-waves 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
= II, III, aVF
- Lateral =
I, aVL, V5-6
inversions are seen with acute myocardial ischaemia.
inversions are seen following infarction, usually in association
with pathological Q waves.
Inferior T wave inversion due to acute ischaemia
Inferior T wave inversion with Q waves due to prior inferior MI
T wave inversion in the lateral leads due to acute ischaemia
Anterior T wave inversion with Q waves due to recent anterior MI
Bundle Branch Block
Left bundle branch block produces
T-wave inversion in the lateral leads I, aVL and V5-6.
Lateral T wave inversion due to LBBB
Right Bundle Branch Block
Right bundle branch block produces
T-wave inversion in the right precordial leads V1-3.
T-wave inversion in the right precordial leads due to RBBB
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.
Lateral T wave inversion 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 inversion in the inferior and right precordial leads due to RVH
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
T wave inversion in the inferior and right precordial leads in a patient
with bilateral PEs
Deep T wave inversion in V1-3 with RBBB in a patient 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 pattern in acute PE
Hypertrophic Cardiomyopathy (HOCM)
HOCM is associated with deep T wave inversions in all the precordial
T wave inversion 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.
Widespread deep T wave inversion due to SAH
Biphasic T waves
Biphasic T waves due to ischaemia
down then up
Biphasic T waves due to hypokalaemia
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.
Wellens’ Type 1
Wellens’ Type 2
‘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’
Prominent U waves due to severe hypokalaemia
Hidden P waves in sinus tachycardia
Hidden P waves in marked 1st degree heart block
Hidden P waves in 2nd degree heart block with 2:1 conduction
Flattened T waves
Dynamic T-wave flattening due to anterior ischaemia (above). T waves
return to normal once the ischaemia resolves (below).
Dynamic T wave flattening due to anterior ischaemia
T waves return to normal as ischaemia resolves
Note generalised T-wave flattening with prominent U waves in the
anterior leads (V2 and V3).
T wave flattening due to hypokalaemia