Tripped by Flips
Brian Smith, DO
Welcome to another rendition of ECG of the Week!
Here we have a short case, but one with a valuable teaching point.
We have a 77 M PMH HTN, HLD sent by PMD for abnormal ECG. The patient states he had a syncopal episode when walking 3 weeks ago. Since then, has been experiencing dyspnea on exertion but no other complaints.
VS: Temp: 36.0, BP: 148/80, HR: 66, RR: 20, O2 sat: 88% on RA.
When you see the patient, he is actually generally well-appearing despite the O2 saturation of 88% on RA. But then you see his ECG (shown below):
Question: How can we clinch the most likely diagnosis?
Ok, so I know what you’re all thinking: “What is going on with these flipped T-Waves EVERYWHERE?”
This ECG looks concerning for sure, but It doesn’t look like anything specific.
But what if I told you when you deeply inverted T-Waves, there are 3 potential diagnoses to consider.
Before we move on try to think of these 3 pathologies and which fits the clinical pictures.
Deeply Inverted T-Waves
Before we get into the answer, let’s review this ECG systematically:
Normal sinus, rate of 66
Normal axis
Normal Intervals
No ST elevations or depressions
BUT THESE DEEP T WAVE INVERSION ARE STARING US IN THE FACE
ECG #1: Our patient - 77 M PMH HTN, HLD sent by PMD for abnormal ECG. The patient states he had a syncopal episode when walking 3 weeks ago. Since then, has been experiencing dyspnea on exertion.
Now, compare the patient’s ECG to these 2:
ECG #2 (left): 77 M PMH uncontrolled HTN who presents after a syncopal episode in the shower, is now obtunded.
ECG #3 (right): 77 M PMH HTN, HLD who presents after a syncopal episode while jogging. He reported chest pain prior to syncope but is now pain free
While at first glance, these ECGs may all seem similar, each patient has a unique, potentially life-threatening diagnosis. There are subtle differences in the histories and ECGS that can clue you into the differences.
Can you guess the diagnosis for each patient?
Answer:
Patient 1: Pulmonary Embolism
Patient 2: Intracranial Hemorrhage
Patient 3: Wellens Syndrome (Type B Pattern)
ECG #2: Cerebral T-Waves
Let’s dissect this further. We’ll start with ECG #2
The differences in T-wave morphology are most obvious in this ECG
Here, we see the T waves are deeply inverted like the other 2
But the major difference in the ECG is the T waves are BROAD-BASED.
You also see grossly Prolonged QT interval due to this wide T wave.
This is known as a “Cerebral T-Wave” and is suggestive of Elevated Intracranial Pressure
If you see this ECG in a patient with a headache, vomiting, syncopal episode, and/or altered mental status, you should have a high suspicion for Intracranial Hemorrhage
Next, lets compare ECG #1 and #3 side-by-side, as the differences between the two are much more subtle:
ECG #1: Patient with Pulmonary Embolism (right) and ECG #3: Patient with Wellens syndrome, Type B (left)
First, the obvious: the T-waves in both of these ECGs look much different than the cerebral T-waves we just discussed. Both are narrow-based, unlike the THICC cerebral T waves.
But there are some subtle differences between ECG 1 and 3 as well.
Wellens Syndrome is critical LAD stenosis. This is reflected on ECG by one fo 2 patterns
Wellen’s A: biphasic T-waves in precordial leads
Wellens B: Deeply inverted T-waves in precoardial leads
Wellens A and B patterns are typically seen in V2 and V3 but CAN extend to all precordial leads (as seen in ECG #3).
However, pulmonary embolism causing acute right heart strain can be reflected on ECG by deep T-wave inversion in the precordial AND inferior leads (as seen in our patient’s ECG)
When reading an ECG, it is always important to consider the CLINICAL CONTEXT as well. PE is more likely in a patient with shortness of breath and hypoxia while Wellens Syndrome is more likely in a patient with resolved exertional chest pain.
Take Home Points:
When you see deeply inverted T-waves, consider PE, Wellens Syndrome Type B or Intracranial Hemorrhage
“Cerebral T-waves”, seen with increased ICP are typically broad-based and prolong the QT interval in comparison to T-wave inversions in PE or Wellens B
With Wellens B, t-wave inversions are typically seen in V2-V3 (and can extend to precordial leads) while with PE, t-wave inversions can be seen in precordial AND inferior leads
Consider clinical picture when interpreting an ECG