Persistent juvenile T-wave pattern

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: Juvenile T waves

The Juvenile T-wave pattern refers to a normal electrocardiographic variant in which T wave inversions are present in the right precordial leads (V₁, V₂, and V₃) along with an early repolarization pattern. Shallow T-wave inversion is usually found in the right precordial leads during infancy, and T wave rises upwards during childhood. If this inverted T-wave pattern sustained to adulthood, it is called persistent juvenile T-wave pattern.

The term Juvenile T-wave pattern was first introduced by American physician David Littman in 1946. ^[1]

Juvenile T-wave resolves completely in 98% of the patients, and those that persist into adulthood demonstrate no adverse sequela.^[2]

• Persistent juvenile T-wave inversion must be differentiated from other diseases that cause T-wave inversion, such as: 
• Arrhythmogenic RV dysplasia should be suspected if the inverted T wave persists beyond lead V₁ in a post pubertal male athlete.
• Cerebrovascular accidents can cause deep widely splayed T waves referred to as cerebral T waves.
• Digoxin effect or Dig effect typically shows the following findings:

• Sinus bradycardia
• T-wave inversions
• T-wave flattening
• U waves
• PR prolongation
• ST-segment depression with a “scooped” appearance
• Short QT due to an abbreviated ventricular action potential

• Hypokalemia can cause T-wave inversion, ST-segment depression, QT prolongation, and U wave.
• Ischemic heart disease including non ST-segment elevation myocardial infarction causes ST-segment depression and non-specific T wave changes.
• Left bundle branch block shows the following criteria on ECG:

• QRS duration is equal or greater than 120 milliseconds
• Absence of Q wave in leads I, V5 and V6
• Monomorphic R wave in I, V5 and V6
• T-wave deflection opposite to the major deflection of the QRS complex

• Left ventricular hypertrophy with strain is characterized by ST-segment depression and T-wave inversion.
• Myocarditis may cause sinus tachycardia, diffuse T-wave inversion, ST-segment elevation without reciprocal depression, and low voltage QRS complexes.
• Premature ventricular contraction is characterized by premature beats in relation to the expected beat, which leads to abnormal morphology and duration of QRS complexes.
• Pulmonary embolism may show inverted T wave in the anterior leads, particularly in massive pulmonary embolism.
• Restrictive cardiomyopathy may show low voltage QRS complexes and inverted T waves.
• Subarachnoid hemorrhage can cause ST-segment elevation and T-wave inversion.^[3]
• Unstable angina may show inverted T wave and ST-segment depression.
• Wellens’ syndrome shows progressive symmetrical deep T-wave inversion in leads V₂ and V_3.
• Wolff-Parkinson-White syndrome (WPW) typically shows slurred upstroke of the QRS complex—known as delta wave—and shortened P wave.

• Juvenile T-wave pattern is more commonly seen in black people—it has been shown in 10.8% of black population and 0.3% of white subjects.^[4]

• Juvenile T-wave pattern is more commonly found in females than males. ^[5][6]

Persistent juvenile T-wave pattern typically shows asymmetric T-wave inversion in V1-V3 without ST-segment elevation.

Persistent juvenile T-wave pattern can be normalized by the following medications: