Another Isolated U Wave Inversion

Report:

Sinus rhythm 95/min

Right atrial abnormality (RAA)

Probable LVH with ST/T changes

Inverted U waves c/w ischæmia

Movement artefact V5.

Comment:

This patient, with chronic emphysema and hypertension, had an episode of chest pain two years previously and was admitted through Casualty with acute coronary insufficiency. The ECG at the time (Fig 72a) showed quite marked diffuse repolarisation changes well beyond what would be expected from LVH alone; these resolved over the following days. Thus, there is little doubt she had established and probably advanced coronary artery disease.

This time round, the evidence is subtler but no less serious. The negative U waves are best seen in V3 and V4, clearly later than the associated upright T waves in the same leads (and elsewhere). The gestalt here resembles Wellens’ syndrome, where it is the terminal T wave which is inverted. The clinical implications are the same.

For some reason, RAA is often seen in association with LVH – the so-called pseudo P pulmonale52. In this case, it is a real McCoy!