Sitaram Mittal | Volume 1; Issue 2 (2020) | Mapsci-JCCR-1(2)-013 | Case Report Citation: Mittal S. T wave inversion localized to lead V3 Only with positive T wave in leads V2 and V4 -A technical error. J Cardiol Cardiovasc Res. 2020;1(2)1-7.
Journal of Cardiology and Cardiovascular Research Sitaram Mittal., 2020- J Cardiol Cardiovas Res
Case Report
T-wave Inversion Localized to Lead V3
Only with Positive T-wave in Leads V2 and
V4 - A Technical Error
Sitaram Mittal*
Abstract
T- wave inversion in electrocardiogram immediately attracts attention
because myocardial ischemia is a common and serious cause. There are,
however, several other, relatively benign, cause that can also cause
inversion of T wave. We observed that medial placement of lead V3
electrode can result in false shallow T wave inversion in lead V3.
Upright T wave in lead V2 and V4 should give a clue to this technical
error. To the best of our knowledge, this cause of T wave inversion
localized to lead V3 only with positive T wave in leads V2 and V4 has
Sitaram Mittal | Volume 1; Issue 2 (2020) | Mapsci-JCCR-1(2)-013 | Case Report Citation: Mittal S. T wave inversion localized to lead V3 Only with positive T wave in leads V2 and V4 -A technical error. J Cardiol Cardiovasc Res. 2020;1(2)1-7.
in normalization of T wave in lead V3
(Figure 2).
Figure 1: Leads V1 to V6 from case 1 with lead
V3 electrode placed along the left sternal
border. T wave is inverted in lead V3 (arrow).
Figure 2: V3 electrode placed midway between
leads V2 and V4. T wave in leads V3 in upright
(arrow).
Case 2
A 62year male with a past history of
coronary artery bypass surgery came for a
treadmill stress test. The previous
electrocardiogram was normal.
Echocardiographic examination was
normal. There was no cardiac chamber
enlargement or regional wall motion
abnormality. Supine ECG showed T wave
inversion in lead V3 (Figure 3).
Figure 3: Leads V1 to V6 from Case 2 V3
electrode placed along the left sternal border. T
wave is inverted in lead V3 (arrow).
T wave was upright in leads V2 and V4. We
suspected that probably like case 1, V3
electrode was wrongly placed.
Correct placement of V3 electrode
normalized T wave polarity (Figure 4).
Sitaram Mittal | Volume 1; Issue 2 (2020) | Mapsci-JCCR-1(2)-013 | Case Report Citation: Mittal S. T wave inversion localized to lead V3 Only with positive T wave in leads V2 and V4 -A technical error. J Cardiol Cardiovasc Res. 2020;1(2)1-7.
Figure 4: Leads V1 to V6 from Case 2 V3
electrode placed midway between leads V2 and
V4. T wave is upright in lead V3 (arrow).
Case 3
A 27year female presented for
cardiovascular evaluation for abnormal
electrocardiogram. She had no
cardiovascular symptoms. The
echocardiogram was normal. The
electrocardiogram showed that T wave
inversion in lead V3 than in lead V2 (Figure
5). Corrected placement of lead V3
electrode normalized the T wave in lead V3
(Figure 6).
Figure 5: Leads V1 to V6 from Case 3 with V3
electrode placed along the left sternal border. T
wave is inverted in lead V3 (arrow).
Figure 6: Leads V1 to V6 from Case 3 with V3
electrode placed midway between leads V2 and
V4. T wave is upright in lead V3 (arrow).
Sitaram Mittal | Volume 1; Issue 2 (2020) | Mapsci-JCCR-1(2)-013 | Case Report Citation: Mittal S. T wave inversion localized to lead V3 Only with positive T wave in leads V2 and V4 -A technical error. J Cardiol Cardiovasc Res. 2020;1(2)1-7.
Discussion
Positions of various precordial leads are
designed to record electric potentials from
different parts of the heart [5] (Figures 7
and 8). V1 electrode is placed in the right
fourth intercostals space along the right
sternal border [2]. It represents electric
potentials from the right atrium. The
electrode of lead V2 is placed in the left
fourth intercostals space along left sternal
border [2] and is supposed to record
electric potential from the base of the
interventricular septum. The electrode of
lead V4 is placed in the left 5th intercostal
space in the midclavicular line [2].
Figure 7: Line diagram showing the normal
position of leads V1 to V6 in relation to
intercostals spaces.
Figure 8: Line diagram showing the relation of
precordial leads to cardiac chambers.
It is supposed to record electric potentials
from the left ventricular apex. The
electrode of lead V3 is placed midway
between lead V2 and V4 [2]. It is supposed
to record electric potential from the
anterior surface of the left ventricle. If lead
V3 electrode is wrongly placed in a medial
position below lead V2 electrode, it overlies
interventricular septum and right ventricle
(Figure 9) and records electric potentials
from the right ventricle, erroneously
recording a negative T wave. This happens
because the vector of the T wave is directed
at an angle of 45 degree away from inter-
ventricular septum4 (Figure 10). This
technical error should be suspected if T
wave is upright in leads V2 and V4 and is
inverted only in lead V3.
Figure 9: Line diagram showing the relation of
the abnormal (medial) position of V3 electrode
(marked as ) to cardiac chambers.
Figure 10: Line diagram showing the relation of
the abnormal (medial) position of V3 electrode
(marked as ) to T wave vector.
Sitaram Mittal | Volume 1; Issue 2 (2020) | Mapsci-JCCR-1(2)-013 | Case Report Citation: Mittal S. T wave inversion localized to lead V3 Only with positive T wave in leads V2 and V4 -A technical error. J Cardiol Cardiovasc Res. 2020;1(2)1-7.
Differential diagnosis of Isolated
Inversion of T wave
Inversion of T wave without any QRS
changes is known as primary T wave
changes. These can be because of several
causes [6].
(a) Normal variations
(i) Persistent juvenile pattern
There is prominent T wave inversion in
right and mid precordial leads. If such a
pattern is associated with left bundle
branch block type ventricular premature
beats or relevant family history, it may
raise the possibility of arrhythmogenic
right ventricular dysplasia [7].
(ii) Anxiety
Changes may normalize on exertion [6].
(iii) Hyperventilation
T wave inversion can occur in normal
persons as well as in persons with coronary
artery disease [8].
(iv) Upright posture [9]
(v) Post prandrial
Physiological electrocardiographic variants
are most likely to occur after meals [9].
(vi) Drinking iced water [9]
(vii) Smoking [9]
Changes may be due to coronary artery
disease or coronary spasm.
(viii) Idiopathic global T wave inversion
[9]
It is usually seen in females. T waves are
inverted in all leads other than lead aVR.
(b) Acute abdominal disorders
Pancreatitis
Cholecystitis
Peritonitis.
(c) Stroke [10]
T waves are broad-based. Q T interval is
prolonged.
(d) Cardiac causes
(i) Early repolarization variant
Prominent biphasic T wave inversion with
mild ST-segment elevation is seen in leads
V1 to V4 [3]. It is usually seen in athletes.
Exercise normalizes T wave inversion.
(ii) Coronary artery disease
Evolution phase of non- ST-
elevation acute coronary syndrome
[3]. T waves are symmetrical but
not deep.
Residual pattern of myocardial
infarction [3].
T waves are deep and symmetrical.
Opposite leads may show a
prominent T wave.
T waves inversion following ST
segment elevation in cases of
Prinzmetal variant angina [6].
Wallens’ pattern Deep T wave
inversion in leads V1 to V4 can
result from severe ischemia
associated with high-grade stenosis
of the proximal left anterior
descending coronary artery [2,11,12].
It is seen in the setting of the acute
coronary syndrome.
T inversion in lead aVL predicts
clinically significant mid LAD
lesion [13,14].
(iii) Pericardial effusion/constriction
Sitaram Mittal | Volume 1; Issue 2 (2020) | Mapsci-JCCR-1(2)-013 | Case Report Citation: Mittal S. T wave inversion localized to lead V3 Only with positive T wave in leads V2 and V4 -A technical error. J Cardiol Cardiovasc Res. 2020;1(2)1-7.
T wave inversion is diffuse and shallow.
There are no reciprocal changes [5].
(iv) Post tachycardia T wave inversion
T wave inversions follow termination of
supraventricular tachycardia, ventricular
tachycardia or ventricular pacing. Such T
wave inversion may persist for hours or
days (memory T wave) [15,16].
(v) Left ventricular apical hypertrophic
cardiomyopathy
Diffuse symmetrical and deep T wave
inversion is present in precordial leads or
inferolateral leads [17].
(vi) Chronic alcoholism
It can produce persistent low voltage
negative T wave [5].
(vi) Mitral valve prolapse
In may show a shallow inversion of T wave
in leads II, III, aVF, V5 and V6 [18].
In all these conditions T wave inversion is
present in two or more consecutive leads.
In Condition T wave, inversion is localized
to a single lead.
Conclusion
Placement of lead V3 along left sternal
border below lead V2 rather than on the
line joining lead V2 and V4 can produce
isolated inversion of T wave in lead V3.
This error should be suspected if T wave is
upright in leads V2 and V4. Recognition of
this technical error can prevent the wrong
diagnosis of myocardial ischemia.
Limitation of our observation
Our observation will not be applicable in
the presence of deformities of the chest
wall, displaced or malpositioned heart,
dilatation of cardiac chambers, presence of
regional wall motion abnormalities, or
intraventricular conduction defects.
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Sitaram Mittal | Volume 1; Issue 2 (2020) | Mapsci-JCCR-1(2)-013 | Case Report Citation: Mittal S. T wave inversion localized to lead V3 Only with positive T wave in leads V2 and V4 -A technical error. J Cardiol Cardiovasc Res. 2020;1(2)1-7.
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