At the Bedside

  • Initial approach
  • Treat anterior T-wave inversion as potentially ischemic until proven otherwise.
  • Assess symptoms: chest pain, resolved chest pain, dyspnea, syncope, palpitations, neuro symptoms, stimulant use, pregnancy/postpartum, PE risk factors.
  • Review prior ECGs whenever possible.
  • Obtain:
  • Serial ECGs.
  • High-sensitivity troponins per institutional pathway.
  • BMP/Mg if arrhythmia concern.
  • CXR if dyspnea/chest pain.
  • Consider bedside echo for RV strain, LV dysfunction, wall motion abnormality, pericardial effusion.
  • Key ECG patterns
  • Wellens syndrome
  • Deeply inverted or biphasic T waves in V2–V3, often extending V1–V6.
  • Minimal or no ST elevation.
  • Pain-free at time of ECG.
  • Normal or mildly elevated troponin.
  • Indicates critical proximal LAD stenosis.
  • Do not stress test. Admit for urgent cardiology/cath.
  • Pulmonary embolism
  • T-wave inversions V1–V4 plus inferior leads may suggest RV strain.
  • Look for tachycardia, S1Q3T3, RBBB, right axis deviation, hypoxia.
  • Evaluate with D-dimer if low/intermediate risk and appropriate; CT pulmonary angiography if indicated.
  • Persistent juvenile T-wave pattern
  • Usually young patients, especially women.
  • Shallow asymmetric T-wave inversion in V1–V3.
  • No symptoms, stable prior ECG, no concerning history.
  • Normal variant
  • Isolated T-wave inversion in V1 may be normal.
  • LVH/RVH strain
  • Repolarization abnormalities with voltage criteria and axis changes.
  • Hypertrophic cardiomyopathy
  • Deep narrow “dagger-like” Q waves, LVH, deep T-wave inversions, syncope/exertional symptoms.
  • CNS catastrophe
  • Deep diffuse T-wave inversions, QT prolongation, bradycardia or autonomic instability; consider SAH/ICH in appropriate presentation.
  • Management decision points
  • Active chest pain/STEMI equivalent/unstable: ACS pathway, cardiology activation as indicated.
  • Wellens pattern: aspirin, cardiac monitoring, cardiology consult, admit for invasive evaluation; avoid stress testing.
  • Possible PE: risk stratify and image/anticoagulate when appropriate.
  • Syncope/exertional symptoms/family sudden death: evaluate for HCM/channelopathy; admit or urgent cardiology depending severity.
  • Clearly benign pattern: only after symptoms, risk factors, biomarkers, and prior ECG support low risk.
A Classic Presentation
A 58-year-old man presents after 30 minutes of substernal chest pressure that resolved before arrival. He is now pain-free. ECG shows biphasic T waves in V2–V3 with no significant ST elevation. Troponin is minimally elevated. He is given aspirin, placed on telemetry, and cardiology is consulted for urgent angiography. Exercise stress testing is avoided because the ECG pattern suggests Wellens syndrome from critical proximal LAD stenosis.

Study Directive

  • Draw from memory the ECG patterns of Wellens type A biphasic and type B deeply inverted T waves.
  • Review 10 ECGs with anterior T-wave inversions and classify each as ischemia, PE/RV strain, benign variant, LVH/RVH strain, or other.
  • Practice saying the disposition out loud: “Wellens = admit, cardiology, no stress test.”
  • Review your ED’s chest pain pathway and heparin/antiplatelet protocol for NSTE-ACS.

Recent Literature