Negative T Waves

A recent literature review by Marcus [11] showed that negative T waves in leads V2-V5 are infrequent over the age of 12 years (Fig. 13.2). In adolescents 12-18 years of age, T wave inversion in V1 and V2 are present in 10%-20% and in up to 5% of adolescents in V3. This juvenile pattern of inverted T waves in leads V1-V3 is observed in 1%-3% of healthy adults aged 19 to 45 years [12]. The location of the precordial recording electrodes can influence ECG pattern and misplaced positioning of lead V2 and V3 could result in false-positive T-wave findings. In addition, there can be lability of the T wave morphology over several days.

Negative T waves in V1-V3 are observed in a majority of patients with ARVC/D (Table 13.2) [13-16]. Preliminary data from the analysis of 89 probands from the North American ARVC/D Registry showed that 58% had negative T waves in V1-V3 or beyond. As shown in Table 13.2, the incidence of T waves inversion in ARVC/D patients range from 19% to 85%. Wichter et al. [17] reported negative T waves in 54% of 151 ARVC/D patients. Turrini et al. [18] analyzed patients with varying degrees of structural abnormalities of the right ventricle. They compared the ECG findings in 20 patients who died suddenly, 20 patients with sustained VT, and 20 patients with no sustained VT. Negative T waves were found in 85%, 70%, and 45% of the cases, respectively, indicating that the extent of myocardial involvement influences fre

Fig. 13.2 • Standard 12-lead ECG in a patient with ARVC/D.There are negative T waves in right precordial leads and premature ventricular beats of left bundle branch block morphology. Note that the QRS is upright in aVL, indicating that the PVB is arising from a location in the right ventricle other than the RVOT

Negative Precordial Waves

Fig. 13.2 • Standard 12-lead ECG in a patient with ARVC/D.There are negative T waves in right precordial leads and premature ventricular beats of left bundle branch block morphology. Note that the QRS is upright in aVL, indicating that the PVB is arising from a location in the right ventricle other than the RVOT

Table 13.2 • Prevalence of the ECG abnormalities in ARVC/D patients by different authors

ECG abnormalities

Nava et al.[13];

Dalal et al.[14];

Lemola et al. [16];

Nasir et al.[15]

N=136

N=69

N=59

N=39

Prolongation of QRS duration in

45

58

59

64

V1-V3 in absence of RBBB

Epsilon wave in V1-V3

4

29

21

33

T wave inversion V1-V3 or beyond

19

81

36

85

Complete RBBB

4

N/a

22

8

QRS dispersion >40 ms

N/a

N/a

N/a

44

Ratio V1+V2+V3/V4+V5+V6>1.2

N/a

N/a

N/a

77

Prolonged S wave upstroke

N/a

91

N/a

95

in V1-V3 >55 ms

Presence of one or more

80

95

N/a

N/a

ECG abnormalities

Normal ECG

20

5

N/a

N/a

Values are presented in percentages

N/a, not available; RBBB, right bundle branch block

Values are presented in percentages

N/a, not available; RBBB, right bundle branch block quency of this ECG finding, which was reported earlier by Nava et al. [3]. Differences in the incidence of negative T waves reported from different series of patients may reflect not only varying degrees of right ventricular dysfunction but also the heterogeneous nature of the ARVC/D, with different penetrance of causative genes. Dalal et al. [8] evaluated phenotypic presentation of ARVC/D patients with and without plakophilin-2 mutation and did not find any difference in the incidence of negative T waves in the two groups. Future studies with large cohorts of geno-typed patients with long-term follow-up will help to determine whether negative T waves are associated with specific gene mutations and whether they appear to indicate severity or progression of the disease.

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