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ST-Segment Depression and T-Wave Inversion: Classification, Differential Diagnosis, and Caveats

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ST-Segment Depression and T-Wave Inversion: Classification, Differential Diagnosis, and Caveats REVIEW CME EDUCATIONAL OBJECTIVE: Readers will distinguish the various causes of ST-segment depression CREDIT and T-wave inversion ELIAS B. HANNA, MD DAVID LUKE GLANCY, MD Cardiovascular Department, Louisiana State Cardiovascular Department, Louisiana State University Health Sciences Center, New Orleans University Health Sciences Center, New Orleans ST-segment depression and T-wave inversion: Classification, differential diagnosis, and caveats ■■ABSTRACT epression of the ST segment and inversion Dof the T wave are common electrocardio- Heightened awareness of the characteristic patterns of graphic abnormalities. Knowing the various ST-segment depression and T-wave inversion is para- ischemic and nonischemic morphologic fea- mount to quickly identifying life-threatening disorders. tures is critical for a timely diagnosis of high- This paper reviews how to distinguish the various causes risk myocardial ischemia and electrolyte- or of these abnormalities. drug-related abnormalities. Moreover, it is important to recognize that true posterior in- ■■KEY POINTS farction or subtle ST-segment elevation infarc- tion may masquerade as ST-segment depression ST-T abnormalities concordant to the QRS complex sug- ischemia, and that pulmonary embolism may gest ischemia. masquerade as anterior ischemia. These com- mon electrocardiographic abnormalities are Deep T-wave inversion or positive-negative biphasic T summarized in TABLE 1. waves in the anterior precordial leads reflect severe left anterior descending coronary artery stenosis. ■ THE ST SEGMENT AND THE T WAVE: A PRIMER Two particular patterns of ST-segment depression reflect Abnormalities of the ST segment and the T ST-segment elevation myocardial infarction rather than wave represent abnormalities of ventricular re- non–ST-segment elevation acute coronary syndrome: polarization. ST-segment depression that is reciprocal to a subtle and The ST segment corresponds to the pla- sometimes overlooked ST-segment elevation, and ST-seg- teau phase of ventricular repolarization ment depression that is maximal in leads V1–V3, suggest- (phase 2 of the action potential), while the T ing true posterior infarction. wave corresponds to the phase of rapid ven- tricular repolarization (phase 3). ST-segment T-wave inversion in the anterior precordial leads may be or T-wave changes may be secondary to ab- normalities of depolarization, ie, pre-excita- seen in cases of acute pulmonary embolism, while flat- tion or abnormalities of QRS voltage or dura- tened T waves with prominent U waves and ST-segment tion. depression may reflect hypokalemia or digitalis therapy. On the other hand, ST-segment and T- wave abnormalities may be unrelated to any QRS abnormality, in which case they are called primary repolarization abnormalities. These are caused by ischemia, pericarditis, doi:10.3949/ccjm.78a.10077 myocarditis, drugs (digoxin, antiarrhythmic 404 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 78 • NUMBER 6 JUNE 2011 HANNA AND GLANCY TABLE 1 Differential diagnosis of ST-segment depression or T-wave inversion Secondary repolarization abnormalities Hypokalemia ST segment and T wave move in the same direction, ST-segment depression discordant to QRS T-wave flattening a Prominent U wave (with the flattened T wave, may mimic a Ischemic ST-segment or T-wave abnormalities wide and notched upright T wave) ST segment or T wave may be concordant to QRS Prolonged QTU interval ST segment and T wave may go in opposite directions Symmetric and pointed T-wave inversion Digitalis effect Positive-negative biphasic T wave Similar to hypokalemia, except that ST-segment depression is typically sagging, T-U wave separation is more distinct, and Wellens syndrome QT interval is shortened Symmetric and deeply inverted T waves OR Takotsubo cardiomyopathy Positive-negative biphasic T wave in leads V2 and V3, occa- ST-segment elevation in the precordial leads or more dif- sionally V1, V4, V5, and V6 fusely PLUS Diffuse T-wave inversion Isoelectric or minimally elevated (< 1-mm) ST segment Prolonged QT interval No precordial Q waves Prolonged QT interval Acute pericarditis History of chest pain in the last hours to days Diffusely inverted or biphasic T waves Pattern present in pain-free state ST-segment elevation has often resolved at this stage Normal or slightly elevated cardiac serum markers Memory inverted T waves True posterior STEMI Appear after pacing, transient left bundle branch block, or transient tachycardia Maximal ST-segment depression in V1–V3 ST-segment elevation in V7–V9 Mild rapidly reversible T-wave abnormalities ST-segment depression reciprocal to subtle ST-segment T-wave inversion occurs with standing, with hyperventilation, elevation or after a meal Subtle ST-segment elevation concomitant to a more marked Persistent juvenile T-wave pattern ST-segment depression in the reciprocal leads T-wave inversion in V1–V3 Decrements between V and V Pulmonary embolism 1 3 Young female (< 40 years old) T-wave inversion in the anterior or inferior leads, or both No other electrocardiographic or clinical abnormality ST elevation in the anterior or inferior leads, or both Sinus tachycardia, rSR’ in V1–V2, right ventricular hypertrophy, Global T-wave inversion rightward QRS axis shift,“P pulmonale” T-wave inversion in most leads except aVR Rapid regression of abnormalities on serial tracings favors T wave sometimes giant (> 10 mm) pulmonary embolism rather than myocardial infarction May be seen with ischemia, intracranial processes, hypertro- phic cardiomyopathy, cocaine use, pericarditis, myocarditis, Takotsubo cardiomyopathy, pulmonary embolism, advanced atrioventricular block aAny one of these features suggests ischemia. ECG=electrocardiogram; LBBB=left bundle branch block; MI=myocardial infarction; PE=pulmonary embolism; STEMI=ST-segment elevation myocardial infarction drugs), and electrolyte abnormalities, par- deviation 40 to 80 ms after the J point, when ticularly potassium abnormalities. all myocardial fibers are expected to have ST-segment deviation is usually measured reached the same level of membrane poten- at its junction with the end of the QRS com- tial and to form an isoelectric ST segment; at plex, ie, the J point, and is referenced against the very onset of repolarization, small differ- the TP or PR segment.1 But some prefer to ences in membrane potential may normally measure the magnitude of the ST-segment be seen and may cause deviation of the J CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 78 • NUMBER 6 JUNE 2011 405 ST DEPRESSION, T INVERSION (A) ST-segment depression and asymmetric T-wave inversion secondary to left ven- tricular hypertrophy (left) and left bundle branch block (right). (B) ST-segment depression and T-wave inversion concordant to QRS, suggestive of ischemia. (C) ST-segment depression with an upright or biphasic negative-positive T wave, sug- gestive of ischemia. (D) Positive-negative biphasic T wave with a minimally elevated J point and an angle of 60 to 90 degrees between the initial ascend- ing portion and the descending portion of the T wave (Wellens-type T-wave abnormal- ity, usually seen in precordial leads V1–V4). This finding is very specific for ischemia. (E) Symmetric and pointed deep T-wave inversion with an isoelectric or a slightly up-sloping or horizontally depressed ST segment (isoelectric: top two panels; slightly up-sloping: third panel; horizontally de- pressed: fourth panel); often follows the biphasic T waves seen in 1D by hours to days. As the T-wave changes subsequently regress, the positive-negative biphasic T- waves are again seen before repolarization returns to normal. FIGURE 1. ST-segment and T-wave morphologies in cases of secondary abnormalities (A) and ischemic abnormalities (B–E). MODIFIED wIth pERMIssION FROM hANNA EB, QUINtAL R, JAIN N. CARDIOLOgy: hANDBOOk FOR CLINICIANs. ARLINgtON, VA: sCRUBhILL pREss; 2009:328-354. 406 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 78 • NUMBER 6 JUNE 2011 HANNA AND GLANCY point and of the early portion of the ST seg- Left ventricular hypertrophy ment.2 Although a diagnosis of ST-segment eleva- tion myocardial infarction (STEMI) that man- dates emergency reperfusion therapy requires ST-segment elevation greater than 1 mm in at least two contiguous leads,3 any ST-segment depression or elevation (≥ 0.5 mm, using the usual standard of 1.0 mV = 10 mm) may be ab- normal, particularly when the clinical context or the shape of the ST segment suggests isch- emia, or when other ischemic signs such as T- wave abnormalities, Q waves, or reciprocal ST- segment changes are concomitantly present. On the other hand, ST-segment depression of FIGURE 2. Example of left ventricular hypertrophy with typ- ical secondary ST-T abnormalities in leads I, II, aVL, V , V , up to 0.5 mm in leads V2 and V3 and 1 mm in 4 5 1 the other leads may be normal. and V6. The QRS complex is upright in these leads while the In adults, the T wave normally is inverted ST segment and T wave are directed in the opposite direc- in lead aVR; is upright or inverted in leads tion, ie, the QRS and the ST-T complexes are discordant. aVL, III, and V1; and is upright in leads I, II, aVF, and V2 through V6. The T wave is con- complex a “reverse checkmark” asymmet- sidered inverted when it is deeper than 1 mm; ric morphology. it is considered flat when its peak amplitude is • The ST and T abnormalities are not dy- between 1.0 mm and –1.0 mm.1 namic, ie, they do not change in the course As we will discuss, certain features allow of several hours to several days. the various causes of ST-segment and T-wave Thus, in cases of left ventricular hyper- abnormalities to be distinguished from one trophy or left bundle branch block, since the another. QRS complex is upright in the left lateral Any ST-segment leads I, aVL, V5, and V6, the ST segment is depression ■ SECOndarY ST-SEGMENT characteristically depressed and the T wave is AND T-wave ABNORMALITIES inverted in these leads (FIGURE 2).
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