Giant T-Wave Inversion in Patients with Acute Coronary Insufficiency

Giant T-Wave Inversion in Patients with Acute Coronary Insufficiency* Mark Fisher, M.D.; Edgar Lichstein, M.D., F.C.C.P.;t Gerald Hollander, M.D., F.C.C.P.;:j: Alvin Greengarl, M.D.;:j: and jacob Shani, M.D. We have observed an electrocardiographic (ECG) pattern of deep T-wave or "giant T wave" invenion in patients with acute coronary insufliciency. We reviewed the ECGs of 936 patients admitted to our coronary ClllR unit during a oneyear period. We found the pattern of giant T-wave inversion was present in nine patients (1 percent). We examined the echocardiograms of all of these patients and we analyzed the coronary angiograms on the seven patients in whom it was performed. We found that giant T-wave inversion was

have observed an electrocardiographic (ECG) W epattern of deep T-wave or "giant T wave" inversion in patients with acute coronary insufficiency. The frequency and significance of this ECG pattern is not clear. Therefore, we performed a retrospective study of patients admitted to our coronary care unit with acute coronary insufficiency in order to determine the frequency and significance of this ECG pattern. METHODS

The ECGs of936 patients admitted to the cardiac intensive care unit during 1988 to 1989 were reviewed. These patients presented with a clinical history of myocardial ischemia as well as ECG changes consisting of ST segment elevation or depression of 1 mm or more or T-wave inversion. Patients whose ECGs consisted ofT-wave inversion greater than or equal to 10 mm in at least two contiguous precordial leads met our criteria for "giant T wave'' inversion and were selected. Patients whose ECGs showed an intraventricular conduction defect or left ventricular hypertrophy were excluded. RESULTS

Giant T-wave inversion was present in the ECGs of nine patients (1 percent); an example is shown in Figure 1. The mean age of the patients was 73.4 years. The clinical data and results of the coronary angiogram and echocardiogram are shown in Thble I. Giant Twave inversion regressed in all patients; all patients survived their hospitalization. *From the Maimonides Medical Center, Division of Cardiology, Department of Medicine, SUNY, Health Science Center at Brooklyn, Brooklyn. tProfessor of Medicine. ~istant Professor of Medicine. Supported in part by a grant from the Maimonides Research and Development Foundation. This study, in part, was presented as a poster presentation at the American Federation fur Clinical ResearCh, Seattle, Wash, May 5, 1991. Manuscript received Julr 2; revision accepted October 1. &print n~quem: Dr: Uclmeira, 4802 'lenth Avenue, Brooklyn 11219

usually found in patients with stenosis in the left coronary system. In addition, the majority of these patients also had echocardiographic evidence ofleft ventricular hypertrophy. We conclude that the high frequency of a partially patent vessel in the left coronary system suggests that this ECG pattern may be useful in identifying patients who might beneGt from coronary revascularization. (Chest 1992; 101:935-37)

DISCUSSION

Patients with coronary artery disease may manifest various ECG changes during myocardial ischemia, ST segment elevation, ST segment depression, or T-wave inversion. We examined an interesting ECG pattern in patients admitted to our cardiac intensive care unit with myocardial ischemia who presented with T-wave inversions greater than or equal to 10 mm in amplitude in at least two contiguous precordial leads during their hospital course. The significance of precordial T-wave inversion in patients with coronary artery disease is well known in that it usually indicates high-grade stenosis in the left anterior descending artery. Shawl et al 1 examined 76 patients who presented with unstable angina and T-wave inversion in the anterior precordial leads. Isolated stenosis of the left anterior descending coronary artery was the most prevalent angiographic finding in all 76 patients. All patients underwent semiemergent angioplasty during their hospital course and follow-up showed that by seven months, 90 percent of the patients who presented with T-wave inversions had complete resolution of this abnormality. In addition, the prognostic implications ofT-wave inversions in the precordial leads are also well known. Granborg et al2 and Sclarovsky et al3 demonstrated that the presence of precordial T-wave inversion in patients presenting with acute coronary insufficiency identifies those at high risk for future cardiac events and a poor long-term prognosis. The significance of giant T-wave inversion in J)iltients presenting with myocardial ischemia has not been well assessed. We observed that its occurrence was rare with the frequency being only 1 percent of the patients who were reviewed. Haines et al4 and de Zwaan et al5 compared ECG patterns with angiographic findings in patients with unstable angina. The patients in their studies had a high CHEST 1101 I 4 I APRIL, 1992

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l. Twelve-lead electrocardiogram showing pattern of giant T-wave inversion.

incidence ofT-wave inversion in the anterior precordial leads occurring in 24 percent and 75 percent, respectively. However, the amplitude ofT-wave inversions in these patients covered a broad range. Therefore, the frequency of giant T-wave inversion in their studies is unknovm and indeed may have also been a rare finding as well. Seven of nine patients who exhibited giant T-wave inversions underwent cardiac catheterization. Six of these patients had angiographic evidence of significant coronary artery disease in the left coronary system.

Although significant stenosis was present in the left anterior descending or left main coronary artery in five patients, one vessel was still patent in all. The patient who had normal coronary arteries had segmental wall motion abnormalities in the left anterior descending artery distribution. Therefore, it appears that the presence of giant T-wave inversion in the anterior precordial leads indicates coronary artery disease that involves the left coronary system with the vessels still patent; this was apparent whether the patient had single-, double- , or triple-vessel disease.

Table 1- Clinical Data, Echocardiographic and Angiographic Findings of Patients with Giant T- Wave lnverlion with Giant T-wave Inversion* Patient No./AJ,:e , yr/Sex

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6182/M

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Coronary Angiographic Data 99% mid-LAD NCA Not performed 100% Dl Not performed 90% prox RCA 99% prox LAD 90% mid-LAD 99% Dl 99%02 90% LCX:PLA 90%mid-RCA 99% Pmx LAD 50% Prox LCX 60% Ostial LMCA 60% Mid-LAD 95% Mid-LAD

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Outcome PTCA Medical Medical Medical Medical PTCA

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*Plus sil(n =present: minus sign= absent; DX =diagnosis; RX =treatment; MI =myocardial infarction; CABG =coronary artery bypass graft; PTCA =percutaneous transluminal coronary angioplasty; QMI = Q-wave Ml; NQMI = non-Q-wave Ml; LAD= left anterior descending artery; NCA =normal coronary arteries; D =diagonal; LCX =left circum8ex artery; LMCA =left main coronary artery; SI =silent ischemia; VA= unstable angina; LVII= left ventricular hypertrophy; and PLA =posterior lateral artery. 936

Giant T - - Inversion in Acute Coronary lnsulftciency (Fi4her et el)

In exploring possible mechanisms for this phenomenon, we noted similar ECG patterns in patients with hypertrophic cardiomyopathy. Yamaguchi et al6 reported 30 patients who had hypertrophic nonobstru~ tive cardiomyopathy with giant negative T waves in the anterior precordial leads. All 30 patients demonstrated high QRS voltage consistent with ECG evidence of left ventricular hypertrophy. It was postulated that the giant negative T waves in this specific group of patients was attributed to apical hypertrophy that was clearly demonstrated by echocardiography. In our study, of the nine patients who demonstrated giant T-wave inversions, six had echocardiographic evidence of left ventricular hypertrophy. Echocardiographic evidence ofleft ventricular hypertrophy was present in four of seven patients who underwent cardiac catheterization. It is possible that giant T-wave inversion in these patients may be due to the combination of ischemia from a partially patent vessel and left ventricular hypertrophy. The left ventricular hypertrophy may have been secondary to longstanding hypertension or may have been a compensatory hypertrophy following a myocardial infarction. We conclude that giant T-wave inversion in patients with myocardial ischemia is an unusual finding. It may occur in single or multivessel disease and is usually associated with disease of the left coronary system. A possible cause may be ischemia in the left coronary system and some degree of left ventricular hypertro-

phy. In addition, the high frequency of a partially patent vessel suggests that this ECG pattern may be u5eful in identifying patients who might benefit from ooropary revascularization. ACKNOWLEDGMENT:~ thank Benita C. Buonanno fur assistance in preparation for our manuscript.

REFERENCES

1 Shawl FA, Velasco CE, Goldbaum TS, Forman MB. Effect of coronary angioplasty on electrocardiographic changes in patients with unstable angina secondary to left anterior descending coronary artery disease. J Am Coll Cardiol1990; 16:325-31 2 Granborg J, Grande P, Pedersen A. Diagnostic and prognostic implications of transient isolated negative T waves in suspected acute myocardial infarction. Am J Cardiol1986; 57:203-07 3 Sclarovsky S, Hechavia E, Strasberg B, Sagie A, Bassevich R, ICusniec J, et al. Unstable angina, ST segment depression with positive vs negative T wave deflections: clinical course, ECG evolution and angiographic correlation. Am Heart J 1988; 116:93341 4 Haines DE, Raabe DS, Gundel WD, Wackers FJTH. Anatomic and prognostic significance of new T wave inversion in unstable angina. Am J Cardioll983; 52:14-8 5 deZwaan C, Bar Fw, Janssen JHA, Cheriex E, Dassen W, Brugada P, et al. Angiographic and clinical characteristi(.'S of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. Am Heart J 1989; 117:657-65 6 Yamaguchi H, Ishimura T, Nishiyama S, Nagasaki F, Nakanishi S, 18katsu F, et al. Hypertrophic nonobstructive cardiomyopathy with giant negative T waves (apical hypertrophy): ventriculographic and echocardiographic features in 30 patients. Am J Cardiol

1979; 44:401-12

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