T-wave Inversions of LVH on the ECG

You may complete the following quiz before reviewing this blog post on LVH (answers to quiz at bottom of post).

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You are a hospitalist in Charleston, SC.  The ED physician has asked for your opinion regarding a patient with chest pain.


Utilizing the H-E-A-R-T Acronym on this ECG, we note the following:



The sum of…

Tallest R + Deepest S = 25 + 23 = 48 mm
This satisfies the criteria of LVH.  (Take note that the age is > 40 years)

No evidence of RAE.  (of note are absent P-waves).  No evidence of LAE.

E……….Extent of Intervals

PR interval…..not applicable since we recognize the absence of P-waves.  Also notice the rhythm is irregularly irregular.  The rhythm is therefore Atrial Fibrillation.  Review the video clip below for an analysis of the origins of A Fib.


QRS Duration = Normal  |  QT interval = Not applicable due to irregular QRS complexes


Since Lead I = positive
and   Lead avF = positive

We therefore know the axis is NORMAL.

R……….qRs-st analysis

No significant Q-waves are noted.

Transition zone between Leads V2 and V3 is normal.

R-wave progression is normal.

ST-depression noted in Leads V2, V3, V4, V5, V6. I, aVL, II, avF


Diffuse T-wave inversion noted.


  1. R + S = 48 mm —- satisfies criteria of LVH.
  2. Absent P-waves with irregularly irregular rhythm – atrial fibrillation.
  3. ST depression Leads V2, V3, V4, V5, V6 I, aVL, II, avF
  4. T-wave inversion Leads I, avL, V1 through V6, II, III, avF.


As you address the letter “T” of the HEART acronym you must look at each lead’s T-wave to judge that it does or does not deviate significantly from its expected configuration i.e. the normal T-wave is characterized as follows (as per agreement we will disregard lead aVR):

Classic T-wave characteristics in ALL Leads:

  1. All upright.  Exception are the T-waves of Leads V1, avL, III, avF (these might be inverted and yet the cardiogram may be perfectly normal).
  2. Asymmetrical.  Rises slowly and has a steep descent.
  3. Low profile (i.e. not tall, peaked or flat).

If a given T-wave of a lead (especially if they occur in associated groups e.g. II, III, avF, etc) deviates from the above triad of characteristics, you must acknowledge this in your interpretation.  These observations might run the gamut of a benign normal variant, to secondary T’s associated with patterns such as LBBB, RBBB, LVH to the Acute MI.  For example, if the T-waves are diffusely flat this could represent hypokalemia, but it could also be a benign variant and might be a chronic pattern for that patient.  Hence the need for comparison with the old cardiogram if available and clinical correlation.

These are the two most common deviations from the Triad listed above and can represent a life-threat:

1.  T-wave inversions.

2.  Peaked T-waves.

This lesson will focus on T-wave inversions.  We will address the peaked T-wave in a later lesson.

The T-wave inversion has a wide range of interpretations with a partial list as follows:  RBBB, LBBB, IVCD, Non-specific changes, Normal variant, Acute MI, Chronic Myocardial ischemia, Pericarditis, SAH, Digitalis effect and LVH to name a few.

Because of the multiple explanations of T-wave inversion, it is important to apply clinical correlation and a careful comparison with the old ECG.  Upon comparison, you may find these changes to be chronic and the patient may indeed need no treatment.  If the changes are new, this may dictate a needed aggressive treatment plan.

The tracing of this Case Study exhibits diffuse T-wave inversion.  This is consistent with myocardial ischemia or infarction especially if the T-wave inversions are new.

Since the patient has LVH, some of the T-wave inversions and ST depressions in the lateral-highlateral leads (I, avL, V4, V5, V6) may be secondary to the LVH pattern, i.e.

“LVH with ST-T changes”

The non-ST elevation MI is typically exhibited by ST depression, T-wave inversion (especially in the associated leads), clinical chest pain and positive cardiac markers (CPK, CKMB, Troponin).  This is grouped into the broad category of the Acute Coronary Syndrome consisting of:

1.  Unstable Angina.
2.  Non-ST elevation MI.
3.  ST elevation MI.


Measured voltage in the precordial leads ……… R + S = 48 mm.

This satisfies the criteria of LVH.  We know that the LVH pattern will often exhibit ST depression and T-wave inversion, especially in  Leads I, avL, V4, V5, V6 (lateral / high-lateral leads).  T-wave inversions are also present in V1, V2, V3, II, III, avF.  These are consistent with and more nearly suggestive of “T-wave inversion of ischemia/infarction”.

This is an example illustrating the need to analyze ST depressions, ST elevations, T-wave inversion.  Please realize that it MIGHT be the superposition contributed by LVH combined with myocardial ischemia/infartion.

The underlying rhythm is atrial fibrillation.

Quiz Answers:

  1.  True
  2.  A, B & C Only
  3. > 35 years old (although many may use 40 years old as a cutoff)
  4.  False


  • LVH with ST-T changes (strain)
  • Diffuse T-wave inversion (cannot rule-out non-ST elevation MI or myocardial ischemia).  Provider must perform pertinent labs, consult with cardiology and compare with an old ECG where available.
  • Atrial Fibrillation with controlled ventricular response

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