Ischæmic Giant T Wave Inversion

Report:

Sinus rhythm

Borderline first degree AV block

PR 0.22”

Incomplete left bundle branch block

QRS 0.12”

Deep T wave inversion consistent with infarction/ischæmia

Prolonged QTc 0.52”

Comment:

The patient had severe multivessel disease, with stenosed graft to the LAD dilated at PTCA the previous year; the left ventricle was normal. There was no explanation but ischæmia for her striking T wave inversion.

Neurogenic giant T wave inversion is, in fact, more asymmetrical and less pointed than this; the T wave is more splayed and the QT interval tends to be longer. Nevertheless, I would not (in fact, was not) sure that her ECG was not a marker of some cerebral event: I went to CCU to find out. Day later, the ECG showed more conventional pattern (106a). The same day, without further symptoms, her T waves normalised (Fig 106b).

A further anginal episode with ST segment depression and its resolution are shown in Figs 106c and 106d.

The conduction defect, reported as LBBB, could also be LAHB with added IVCD: the timing of secondary R wave in aVR with respect to aVL and the RS pattern in V6 support LAHB rather than LBBB. This does not matter much.