T wave inversion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: negative T wave; negative T waves; inverted Ts;flipped T waves; flipped T wave; flipped Ts

Overview

T wave inversion is a non-specific electrocardiographic sign in which the T wave, an electrical signal that occurs when the heart is repolarizing or recharging itself, it is upside down instead of upright.

Classification

Primary T Wave Inversion

These changes in the T wave represent a primary abnormality in electrical repolarization (i.e. they are not due to or secondary to a change in conduction). Examples include the dig effect, myocardial ischemia or central nervous system events such as subarachnoid hemorrhage.

Secondary T Wave Inversion

The T wave may be inverted as a result of changes in the sequence of ventricualr activation such as is seen with premature ventricular contractions (PVCs), left bundle branch block, right bundle branch block (RBBB) and pre excitation syndromes like WPW.

Causes

• Arrhythmogenic RV dysplasia should be suspected in this cohort if the T wave inversion persists beyond lead V₁ in a post pubertal male athlete
• Cerebrovascular accidents can cause deep widely splayed T waves referred to as cerebral T waves
• Digoxin effect or Dig effect
• Electrolyte disturbance
• Ischemic heart disease including non ST segment elevation MI or prior MI
• Left bundle branch block, it is normal for the T wave to be inverted if the QRS complex is upright
• Left ventricular hypertrophy with strain
• Myocarditis
• Persistent juvenile T-wave pattern
• Premature ventricular contraction
• Pulmonary embolism, particularly in the anterior precordium
• Restrictive cardiomyopathy
• Subarachnoid hemorrhage
• Unstable angina
• Wellens' syndrome
• Wolff-Parkinson-White syndrome (WPW)

Causes by Organ System

Cardiovascular	Acute pericarditis, Advanvced AV block, Angina, Arrhythmogenic right ventricular dysplasia, Atrioventricular reentry tachycardia with orthodromic conduction, Bundle branch block, Global T-wave inversion, Hypertrophic cardiomyopathy, Memory T-wave phenomenon, Myocardial infarction, Myocardial ischemia, Myocarditis, Persistent juvenile T-wave pattern, Pre-excitation syndrome, Pulmonary embolism, Restrictive cardiomyopathy, Stress cardiomyopathy, Takotsubo cardiomyopathy, Ventricular ectopic beats, Ventricular hypertrophy with strain, Wellens' syndrome, WPW syndrome, Brugada syndrome
Chemical / poisoning	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	Cocaine, Digitalis, Digoxin
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	Brugada syndrome
Hematologic	Anemia
Iatrogenic	After surgery, Ventricular paced beats
Infectious Disease	No underlying causes
Musculoskeletal / Ortho	No underlying causes
Neurologic	Cerebrovascular accident, Intracranial hemorrhage, Raised intracranial pressure, Status epilepticus
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	No underlying causes
Oncologic	No underlying causes
Opthalmologic	No underlying causes
Overdose / Toxicity	Cocaine, Digitalis, Digoxin
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal / Electrolyte	Electrolyte abnormalities, Hypokalemia
Rheum / Immune / Allergy	No underlying causes
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	No underlying causes
Dental	No underlying causes
Miscellaneous	Cocaine, After meals, Fever, Hyperventilation, Lead aVR of normal ECG, Normal finding in children, Normal variant of repolarization, Standing

Causes in Alphabetical Order

Acute pericarditis Advanvced AV block After meals After surgery Anemia Angina Arrhythmogenic right ventricular dysplasia Atrioventricular reentry tachycardia with orthodromic conduction Brugada syndrome Bundle branch block Cerebrovascular accident Cocaine Digitalis Digoxin Electrolyte abnormalities Fever Global T-wave inversion Hypertrophic cardiomyopathy Hyperventilation Hypokalemia Intracranial hemorrhage

Lead aVR of normal ECG Memory T-wave phenomenon Myocardial infarction Myocardial ischemia Myocarditis Normal finding in children Normal variant of repolarization Persistent juvenile T-wave pattern Pre-excitation syndrome Pulmonary embolism Raised intracranial pressure Restrictive cardiomyopathy Standing Status epilepticus Stress cardiomyopathy Takotsubo cardiomyopathy Ventricular ectopic beats Ventricular hypertrophy with strain Ventricular paced beats Wellens' syndrome WPW syndrome