T wave

Dr Budi Enoch
SpPF
The T wave is the positive deflection after each QRS
complex.
It represents ventricularrepolarisation
Characteristics of the normal T wave

Upright in all leads except aVR and

V1
Amplitude < 5mm in limb leads, <
15mm in precordial leads
Duration (seeQT 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.
 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

Loss of 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.
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.
 Inverted T waves
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).
Myocardial Ischaemia and Infarction

T-wave inversions due tomyocardial

ischaemiaor 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
DynamicT-wave inversions are seen with
acute myocardial ischaemia.
FixedT-wave inversions are seen following
infarction, usually in association with
pathological Q waves.
 Inferior T wave inversion due to acute
ischaemia
T wave inversion in the lateral
leads due to acute ischaemia
 Anterior T wave inversion with Q
waves due to recent anterior MI
 Left Bundle Branch Block
bundle branch blockproduces 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 blockproduces T-wave
inversion in the right precordial leads V1-3.
T-wave inversion in the right precordial
leads due to RBBB
 Left Ventricular Hypertrophy
Left ventricular hypertrophyproduces 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 hypertrophyproduces 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
 Biphasic T waves

There are two main causes of biphasic

T waves:
Myocardial ischaemia
Hypokalaemia
The two waves go in opposite
directions:
IschaemicT waves go up then down
HypokalaemicT waves go down
then up
 Biphasic T waves due to ischaemia

Biphasic T waves due to hypokalaemia

 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
 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 wavesfused to the end of the
T wave, as seen in severe hypokalaemia
Hidden P wavesembedded in the T wave, as
seen in sinus tachycardia and various types of
heart block
 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

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).
Dynamic T wave flattening due to anterior ischaemia
T waves return to normal as ischaemia resolves
TERIMA KASIH