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T wave inversions do not always mean ischemia! Consider the following comprehensive differential for TWIs:
Coronary artery disease (Wellens, ischemia, reperfusion)
Neurological causes (elevated intracranial pressure)
Pulmonary causes (PE, pneumothorax, pulmonary HTN, pneumonia, hyperventilation, etc.)
Post-tachycardia, post-shock, post-pacing (“cardiac memory”)
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (V1-V3)
Brugada syndrome (V1-V2)
Wide QRS complexes (BBB’s. PVC’s, Paced rhythms, WPW)
High left ventricular voltage, LVH with strain pattern
Pericarditis, myocarditis
Hyperkalemia, hypokalemia
Juvenile T-wave pattern
Mitral valve prolapse
Normal finding in V1, aVR, and lead III
The following is a list of important causes of TWIs specifically in leads V1-V3:
Coronary artery disease (ischemia)
Pulmonary causes (PE, pneumothorax, pulmonary HTN, pneumonia, hyperventilation, etc.)
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (V1-V3)
Brugada pattern
Juvenile T-wave pattern
RBBB
KEY PEARL:
Several conditions may cause T-wave inversions (TWIs). TWI's do not always mean ischemia!
It is important to correlate clinically and know your differential diagnosis for TWI's!
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