ECG Review-T Wave Inversion After PSVT Conversion

By Ken Grauer, MD

Clinical Scenario: The ECG shown in the Figure was obtained from a previously healthy 42-year-old man who presented to the emergency department in PSVT at a rate of just under 150 beats/minute (follow-up tracing to last month’s ECG Review). The patient had been experiencing atypical chest discomfort that completely resolved after treatment of his arrhythmia. The ECG shown was recorded 10 minutes after conversion to normal sinus rhythm. Should this patient be admitted to the hospital to rule out acute infarction?

Interpretation: As noted above, the patient now has converted to normal sinus rhythm, as evidenced by regular upright P waves in lead II. The most remarkable finding on this tracing is the presence of fairly deep, symmetric T wave inversion in the inferior and lateral precordial leads. The point to emphasize is that other than ischemia, this T wave inversion most probably represents the "post-tachycardia" syndrome, in which transient T wave inversion (lasting hours or more) may be seen without necessarily reflecting coronary ischemia. Whether to admit this patient should depend on the clinical situation (i.e., not necessarily needed if symptoms have completely resolved and the patient is an otherwise healthy young adult without any evidence of underlying heart disease). Bonus—this post-tachycardia tracing confirms that the terminal negative notching of the QRS complex in the inferior leads and the terminal r’ in lead V1 of last month’s ECG Review tracing was in fact the result of retrograde atrial activity during the reentry tachycardia.