T Wave

Aka: T Wave, Peaked T Wave, Tall T Wave, Prominent T Wave, Hyperacute T Wave, T Wave Inversion, T Wave Alternans, Flattened T Wave, T Wave Flattening, Deep T Wave Inversion, Cerebral T Waves

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II. Definitions

  1. T Wave
    1. EKG electrical signal following the ST Segment
    2. Represents repolarization of the ventricular Muscles

III. Findings: Normal

  1. Upright: I, II, V3, V4, V5, V6
  2. Inverted: aVR
  3. Variable (upright, inverted or biphasic): all other leads
  4. Increased Amplitude: aVL and aVF (if QRS over 5 mm)
  5. Shape: Asymmetrical
    1. An upright T Wave normally rises gradually, and falls with a steeper slope

IV. Findings: T Wave Shape

  1. Smooth: Normal
  2. Notched: Pericarditis
  3. Pointed: Myocardial Infarction
  4. T Wave Alternans
    1. Upright T Wave alternates with inverted T Wave on every other beat
    2. May be associated with Prolonged QTc (as well as predisposing Hypokalemia or Hypocalcemia)
    3. Marker of myocardial electrical instability
      1. Ominous finding that heralds ventricular Dysrhythmia, Torsades de Pointes or Cardiac Arrest

V. Findings: T Wave Height

  1. See Tall P Waves below
  2. Normal
    1. Limb leads: <6 mm
    2. Precordial leads: < 10 mm
  3. T-Wave Flattening (T Wave height -1 to 1 mm)
    1. Post-coronary ischemic event
    2. Hypokalemia
    3. Digitalis

VI. Causes: Tall, peaked, prominent or Hyperacute T Wave Causes

  1. Hyperkalemia
    1. See Hyperkalemia Related EKG Changes
    2. T Waves are narrow, tall and symmetric
    3. T Waves may be inverted (negatively peaked)
  2. Myocardial Infarction or Myocardial Ischemia
    1. T Waves are less tall and more wide and asymmetric than in Hyperkalemia
    2. De Winter T Wave is a Hyperacute T Wave with J Point depression and consistent with acute LAD Occlusion
    3. Prominent T Waves often immediately precede ST Elevation in STEMI
      1. Obtain Serial EKGs
      2. AHA/ACC consider Hyperacute T Waves in ACS presentation as a STEMI Equivalent (consult cardiology)
      3. However, grading T Wave size is subjective, and there is no T height calculation that reliably predicts high risk ACS
        1. T Waves that are as tall or taller than the QRS Complex are significant
        2. Observe for associated ST deviation >=1mm or dynamic T Wave changes
        3. AVL T Wave Inversion precedes inferior Myocardial Infarction
  3. Other Causes of Tall T Waves
    1. Cerebrovascular Accident
    2. Acute Pericarditis
    3. Left Ventricular Hypertrophy
    4. Early Repolarization
    5. High voltage EKG
    6. Left Bundle Branch Block
    7. Preexcitation Syndrome
  4. References
    1. Mattu (2008) Crit Dec Emerg Med 33(12): 11
    2. Mattu and Swaminathan (2023) EM:Rap, accessed 10/1/2023
    3. Koechlin (2023) Ann Emerg Med 82(2):194-202 +PMID: 36774205 [PubMed]
    4. Smith (2023) Ann Emerg Med 82(2):203-6 +PMID: 36872197 [PubMed]

VII. Causes: T Wave Inversion

  1. Very Deep T Wave Inversion (Cerebral T Waves)
    1. Associated with large Intracranial Hemorrhage (also seen in cerebral edema, Ischemic CVA, PRES)
    2. Typically in precordial leads, and Inversion may be >20 mm
    3. May be associated with Prolonged QTc
    4. Images: Deep Inverted T Waves Precordial in Hypertensive Encephalopathy (PRES)
      1. ekg20214c_1_deepInvertedTwavesPRES.jpg
      2. ekg20214c_2_deepInvertedTwavesPRES.jpg
      3. ekg20214c_3_deepInvertedTwavesPRES.jpg
    5. References
      1. Mattu and Brady (2008), EKGs for the Emergency Physician 2, BMJ, London, p. 11, 23
      2. Mattu (2022) Crit Dec Emerg Med 36(3): 7
  2. T Wave Inversion (in general)
    1. Heart Block
    2. Ischemic Heart Disease with Myocardial Ischemia or infarction
    3. Bradycardia
    4. Right Ventricular Hypertrophy
    5. Right Bundle Branch Block
    6. Metabolic disturbance
    7. Takotsubo Cardiomyopathy
    8. Pulmonary Edema
    9. Cocaine Use
    10. Acute CNS events
    11. References
      1. Said (2015) World J Cardiol 7(2): 86-100 +PMID:25717356 [PubMed]
      2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4325305/
  3. T Wave Inversion specific to anterior leads (V1 to V4)
    1. Juvenile T Wave Pattern
      1. T Wave Inversion is normal in V1-V3 in age <16 years (athletes and non-athletes)
    2. Anterior Myocardial Ischemia
    3. Proximal Left Anterior Descending Occlusion
      1. See Wellen's Syndrome
      2. Deeply inverted T Waves or biphasic T Waves in V2-3
    4. Posterior Myocardial Infarction
    5. Pulmonary Embolism with right heart strain
    6. Neurogenic T Waves
      1. Precedes ischemic cerebrovascular event
    7. Yamaguchi Syndrome
      1. Hypertrophic Cardiomyopathy involving the cardiac apex
    8. Hypokalemia
      1. Biphasic T Wave in mid-precordial leads
      2. Mattu (2017) Crit Dec Emerg Med 31(3): 11
    9. References
      1. Herbert (2012) EM:RAP 12(1): 12

VIII. References

  1. Berberian (2023) Crit Dec Emerg Med 37(5): 12-3

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Related Studies

Ontology: Flattened T wave (finding) (C0429059)

Concepts Finding (T033)
SnomedCT 66812002, 142100009
Italian Ampiezza ridotta dell'onda T nell' elettrocardiogramma, Ampiezza dell'onda T diminuita, Appiattimento dell'onda T, Ampiezza della T diminuita
English Flattened T wave (finding), T wave amplitude decreased, Electrocardiogram T wave amplitude decreased, T amplitude decreased, T wave flattening of, Depressed T wave, Flattened T wave
Dutch T-amplitude verlaagd, T-golfamplitude verlaagd, T-golf afvlakking, elektrocardiogram T-golf amplitude verlaagd
French Amplitude T diminuée, Amplitude de l'onde T diminuée, Aplatissement de l'onde T, Onde T d'amplitude diminuée à l'électrocardiogramme
German T-Amplitude erniedrigt, T-Wellen-Amplitude erniedrigt, T-Wellenabflachung, Elektrokardiogramm T-Wellen-Amplitude erniedrigt
Portuguese Amplitude de T diminuída, Achatamento da onda T, Amplitude da onda T diminuída, Amplitude da onda T diminuída (ECG)
Spanish T de amplitud disminuida, Aplanamiento de la onda T, Amplitud disminuida de la onda T, amplitud disminuida de la onda T, onda T aplanada (hallazgo), onda T aplanada, amplitud disminuida de la onda T (hallazgo), Amplitud disminuida de la onda T del electrocardiograma
Japanese Ｔ波平低化, 心電図Ｔ波振幅減少, Ｔ波振幅減少, Tﾊｼﾝﾌﾟｸｹﾞﾝｼｮｳ, ｼﾝﾃﾞﾝｽﾞTﾊｼﾝﾌﾟｸｹﾞﾝｼｮｳ, Tﾊﾍｲﾃｲｶ
Czech Snížení amplitudy T vlny na elektrokardiogramu, Snížená amplituda T vlny, Snížení T amplitudy, Zploštění T vlny
Hungarian T hullám amplitúdó csökkent, T hullám ellaposodása, T amplitúdó csökkent, Elektrokardiogram T hullám amplitúdó csökkent
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Tall T wave (C0429060)

Concepts Finding (T033)
SnomedCT 251237002
English Tall T wave, Tall T wave (finding)
Spanish onda T alta, onda T elevada (hallazgo), onda T elevada
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: T wave feature (C0429103)

Concepts Finding (T033)
SnomedCT 142097004, 41011002
English T wave feature, t waves, t wave, T wave (observable entity), T wave, T wave feature (observable entity)
Spanish onda T (entidad observable), onda T
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Inverted T wave (C0520888)

Definition (NCI) An electrocardiographic finding of an inversion of the T wave from the expected axis.
Definition (NCI_CDISC) An electrocardiographic finding of an inversion of the T wave from the expected axis. (NCI)
Concepts Finding (T033)
SnomedCT 59931005, 142101008
Italian Inversione dell'onda T dell'elettrocardiogramma, Onde T invertite, Inversione dell'onda T, Onda T invertita, Onda T negativa, T invertita
English T wave inversion, electrocardiogram T. waves inverted, inverted T waves, Electrocardiogram T wave inversion, T wave inversion of, T inverted, Inverted T waves, T wave inverted, electrocardiogram: inverted T waves (procedure), electrocardiogram: inverted T waves, inverted t wave, inversions t wave, inverted t, inversion t wave, inverted t waves, ekg t wave inversion, t wave inverted, negative t wave, t wave inversion, T wave inversion in EKG, T Wave Inversion by ECG Finding, T Wave Inversion, T Wave Inversion by EKG Finding, T WAVE INVERSION, Negative T wave, Inverted T wave (finding), Inverted T wave
Dutch T-golf geïnverteerd, T-golf inversie, T-golf inversie van, geïnverteerde T-golven, negatieve T-golf, T geïnverteerd, elektrocardiogram T-golf omkering
French Ondes T inversées, Inversion de l'onde T, Onde T négative, T inversé, INVERSION ONDE T, Onde T inversée à l'électrocardiogramme
German T-Welle umgekehrt, T-Wellen-Umkehrung, umgekehrte T-Wellen, T-Negativierung, T umgekehrt, Elektrokardiogramm Umkehrung der T-Welle
Portuguese Ondas T invertidas, Inversão da onda T, Onda T invertida, Onda T negativa, T invertida, INVERSAO DA ONDA T, Inversão da onda T (ECG)
Spanish T invertida, Onda T invertida, Ondas T invertidas, Inversión de la onda T, Onda T negativa, inversión de la onda T, inversión de la onda T (hallazgo), inversión de la onda T en el electrocardiograma, inversión de la onda T en el electrocardiograma (hallazgo), Inversión de la onda T del electrocardiograma
Japanese 陰性Ｔ波, 心電図Ｔ波逆転, Ｔ波逆転, Ｔ逆転, ｼﾝﾃﾞﾝｽﾞTﾊｷﾞｬｸﾃﾝ, Tﾊｷﾞｬｸﾃﾝ, ｲﾝｾｲTﾊ, Tｷﾞｬｸﾃﾝ
Czech Inverze T vlny na elektrokardiogramu, Invertovaná T vlna, T vlna negativní, Invertované T vlny, Invertované T, Inverze T vlny
Hungarian T hullám inverzió, T hullám fordított, Elektrokardiogram T hullám inverzió, Fordított T hullám, T fordított, Negatív T hullám
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: T wave alternans (C1998313)

Definition (NCI) An electrocardiographic finding in which there are variations in the shape, amplitude, or direction of the T wave from one beat to the next.
Definition (NCI_CDISC) An electrocardiographic finding in which there are variations in the shape, amplitude, or direction of the T wave from one beat to the next.
Concepts Finding (T033)
SnomedCT 428550008
English T wave alternans (observable entity), T wave alternans, T Wave Alternans, T Wave Alternans by EKG Finding, T Wave Alternans by ECG Finding, T WAVE ALTERNANS
Spanish onda T alternante, onda T alternante (entidad observable)
Derived from the NIH UMLS (Unified Medical Language System)

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