T wave inversion

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

Synonyms and keywords: negative T wave; negative T waves; inverted Ts;flipped T waves; flipped T wave; flipped Ts

T wave inversion is a non-specific electrocardiographic sign in which the T wave, an electrical signal that occurs when the heart is repolarizing or recharging itself, it is upside down instead of upright.

These changes in the T wave represent a primary abnormality in electrical repolarization (i.e. they are not due to or secondary to a change in conduction). Examples include the dig effect, myocardial ischemia or central nervous system events such as subarachnoid hemorrhage.

The T wave may be inverted as a result of changes in the sequence of ventricualr activation such as is seen with premature ventricular contractions (PVCs), left bundle branch block, right bundle branch block (RBBB) and pre excitation syndromes like WPW.

• Arrhythmogenic RV dysplasia should be suspected in this cohort if the T wave inversion 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
• Electrolyte disturbance
• Ischemic heart disease including non ST segment elevation MI or prior MI
• Left bundle branch block, it is normal for the T wave to be inverted if the QRS complex is upright
• Left ventricular hypertrophy with strain
• Myocarditis
• Persistent juvenile T-wave pattern
• Premature ventricular contraction
• Pulmonary embolism, particularly in the anterior precordium
• Restrictive cardiomyopathy
• Subarachnoid hemorrhage
• Unstable angina
• Wellens’ syndrome
• Wolff-Parkinson-White syndrome (WPW)