A 77-year-old woman came to the emergency department with dyspnea and T-wave inversions that became deeper and more diffuse over the next 15 hours (Figure). T waves were inverted, in most leads symmetrically, in all leads except aVR and V1, and the QT interval (604 ms with a QTc of 643 ms) was markedly prolonged. Walder and Spodick described this electrocardiographic pattern as global T-wave inversion, found it in 100 of 30,000 consecutive electrocardiograms, and noted that 82 of the patients were women (1). Others have used the term diffuse T-wave inversion for this widespread T-wave inversion which always shows a reciprocal upright T wave in lead aVR and may also spare leads V1, III, and/or aVL (2). When unusually deep inversion of the T waves is the most salient feature of global T-wave inversion, the condition is sometimes referred to as giant negative T waves.
Figure.
This electrocardiogram of a 77-year-old woman with dyspnea was recorded 15 hours after admission. See text for explication.
The most common cause of global T-wave inversion is myocardial ischemia. This patient's troponin I peaked at 2.4 ng/mL (reference, <0.05). Her echocardiogram and angiographic left ventriculogram revealed severe hypokinesis to akinesis of the anterolateral wall and apex with an ejection fraction of 35%, and the chest radiograph showed florid pulmonary edema. Because she had no history of prior myocardial infarction and because the troponin I was only slightly elevated on the current admission, most of the left ventricular dysfunction was probably due to ischemic stunning. Coronary arteriography displayed the genesis of the stunning: a 90% distal left main narrowing extending into and severely narrowing the proximal left anterior descending coronary artery and the proximal left circumflex coronary artery, including its immediate bifurcation into a large obtuse marginal branch and an even larger posterior division. There was essentially no distal disease of the left coronary artery, and the right coronary artery appeared to be normal.
The Table lists other causes of global T-wave inversion (1–5). Prominent among these are intracranial hemorrhage (3) and the more recently described stress-induced myocardial stunning (4, 5). The prognosis in patients with global T-wave inversion is determined by the underlying cause and the management thereof (6). Our patient underwent successful coronary artery bypass grafting, and treatment of her systemic hypertension, hyperlipidemia, and obesity has begun.
Table.
Some causes of global
| T-wave inversion |
| Myocardial ischemia |
| Intracranial hemorrhage |
| Other central nervous system disease |
| Pericarditis |
| Myocarditis |
| Hypertrophic cardiomyopathy |
| Stress-induced myocardial stunning |
| Metabolic abnormalities |
| Cocaine use |
| Pheochromocytoma |
| Nonischemic pulmonary edema |
| High-grade atrioventricular block |
| Aftereffect of cardiac arrest |
| Cardiac metastases |
References
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