T wave
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Overview
The T wave represents the repolarization (or recovery) of the ventricles. The interval from the beginning of the QRS complex to the apex of the T wave is referred to as the absolute refractory period. The last half of the T wave is referred to as the relative refractory period (or vulnerable period).
Orientation of T waves
Normal Orientation
General
- Normally upright in leads 1 and 2 and in the chest leads over the left ventricle.
Precordial Leads
- Lead V1 may have a positive, negative, or biphasic T wave.
- The T wave in V1 may be inverted at any age (is more often inverted than upright) and the T in V2 can normally be inverted.
- When the T in V1 is upright, it is almost never as tall as the T in V6.
- In infants and young children precordial T waves may be inverted.
- In adult males it is considered abnormal if the T waves are inverted as far to the left as lead V3.
- In adult females the T in V3 may be shallowly inverted.
aVF
- Normally upright in aVL and aVF if the QRS is > 5 mm tall but may be inverted if the R waves are smaller.
- It is not uncommon to have an isolated negative T wave in lead III, aVL, or aVF. Cardiologists are often asked to consult pre-operativley on the patient with the isolated flipped T in lead III.
aVR
- Normally inverted in aVR.
In The Presence of Conduction Delay
- When a conduction abnormality (e.g., left bundle branch block,right bundle branch block, or a paced rhythm) is present, the T wave should be deflected opposite the terminal deflection of the QRS complex. This is known as appropriate T wave discordance.
Differential Diagnosis of Inverted or Negative T waves:
- Coronary ischemia
- Left ventricular hypertrophy
- CNS disorder.
Morphology of T waves
Shape
Notched
- Notched in children and in adults with Pericarditis
Differential diagnosis of the sharp, tented or pointed T wave
- Tall or "tented" symmetrical T waves may indicate hyperkalemia.
- One of the earliest electrocardiographic finding of acute myocardial infarction is sometimes the hyperacute T wave, which can be distinguished from hyperkalemia by the broad base and slight asymmetry.
- T waves can be sharply pointed in ischemia as well.
Height
The T wave is normally not taller than > 5 mm in any standard lead and not taller than > 10 mm in any precordial lead.
Differential diagnosis of the tall T wave:
- Hyperkalemia
- Left ventricular hypertrophy
- Myocardial Ischemia
- Myocardial infarction
- Ventricular strain
- Psychosis
- Cerebrovascular accident (usually inverted, widely splayed, frequently in subarrachnoid hemorrhages)
Differential diagnosis of the short or flat T wave:
- Coronary ischemia
- Hypokalemia.
- Obesity. This finding may reverse with weight loss
Examples
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Additional resources
- ECGpedia: Course for interpretation of ECG
- The whole ECG - A basic ECG primer
- 12-lead ECG library
- Simulation tool to demonstrate and study the relation between the electric activity of the heart and the ECG
- ECG information from Children's Hospital Heart Center, Seattle
- ECG Challenge from the ACC D2B Initiative
- National Heart, Lung, and Blood Institute, Diseases and Conditions Index
- A history of electrocardiography
- EKG Interpretations in infants and children
Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
