Large T wave inversion and QT prolongation associated with pulmonary edema: a report of nine cases

Long QT and Cardiac Arrest After Symptomatic Improvement of Pulmonary Edema

A case of extreme QT prolongation induced following symptomatic resolution of acute pulmonary edema is both relatively unknown and poorly understood.

Late T-wave inversion following resolution of non-ischemic acute pulmonary edema

Electrocardiographic (ECG) changes occurring several hours after the onset of acute cardiogenic pulmonary edema have been seldom described. The proposed explanatory mechanisms are various and not fairly established. In the absence of significant coronary artery disease, these ECG abnormalities could be attributed to mechanisms implicated in coronary microcirculatory dysfunction.

Extreme QT prolongation in elderly women after non-ST elevation myocardial infarct

This is a brief report of three cases of non-ST elevation myocardial infarction presenting with giant T wave inversion and prolonged QT interval. Searching the medical literature revealed a handful of similar cases. There were quite a few common characteristics among these cases suggesting an uncommon but distinctive presentation.

The pathogenesis of reversible T-wave inversions or large upright peaked T-waves: Sympathetic T-waves

Reversible electrocardiographic (ECG) repolarization changes including T-wave inversions (TWI), large upright peaked T-waves (LUPTW) and prolongation of the corrected QT interval (P-QTc) have been reported in association with myriads of acute cardiac and non-cardiac diseases. Through the last 70 years, the TWIs have been described under different terms as; cerebral, giant, global, canyon, Wellens or coronary and cardiac memory T waves. During the last 15 years, the reversible TWI and LUPTW in association with P-QTc have been described as characteristic ECG features in takotsubo syndrome (TS), which also may be triggered by the same aforementioned acute cardiac and non-cardiac disease entities. The pathogenesis of these reversible T-wave changes is not clear-cut. In this manuscript, substantial evidences for a causal link between the local cardiac sympathetic disruption and the development of the reversible TWI and LUPTW are presented. As a result, a pathogenetic term for the reversible TWI or LUPTW, which is sympathetic T waves (sympathetic TWI or sympathetic LUPTW), would be the most appropriate term.

Cardiac and non-cardiac causes of T-wave inversion in the precordial leads in adult subjects: A Dutch case series and review of the literature

AIM: To describe the electrocardiographic (ECG) phenomena characterized by T-wave inversion in the precordial leads in adults and to highlight its differential diagnosis.

METHODS: A retrospective chart review of 8 adult patients who were admitted with ECG T-wave inversion in the anterior chest leads with or without prolongation of corrected QT (QTc) interval. They had different clinical conditions. Each patient underwent appropriate clinical assessment including investigation for myocardial involvement. Single and multimodality non-invasive, semi-invasive and invasive diagnostic approach were used to ascertain the diagnosis. The diagnostic assessment included biochemical investigation, cardiac and abdominal ultrasound, cerebral and chest computed tomography, nuclear medicine and coronary angiography.

RESULTS: Eight adult subjects (5 females) with a mean age of 66 years (range 51 to 82) are analyzed. The etiology of T-wave inversion in the precordial leads were diverse. On admission, all patients had normal blood pressure and the ECG showed sinus rhythm. Five patients showed marked prolongation of the QTc interval. The longest QTc interval (639 ms) was found in the patient with pheochromocytoma. Giant T-wave inversion (≥ 10 mm) was found in pheochromocytoma followed by electroconvulsive therapy and finally ischemic heart disease. The deepest T-wave was measured in lead V₃ (5 ×). In 3 patients presented with mild T-wave inversion (patients 1, 5 and 4 mm), the QTc interval was not prolonged (432, 409 and 424 msec), respectively.

CONCLUSION: T-wave inversion associated with or without QTc prolongation requires meticulous history taking, physical examination and tailored diagnostic modalities to reach rapid and correct diagnosis to establish appropriate therapeutic intervention.

Cardiac memory during rather than after termination of left bundle branch block

An 83-year-old woman with chronic left bundle branch block and remote history of pacemaker implantation for intermittent AV block was hospitalized for fatigue and leg swelling. She had no cardiac complaints. Routine 12-lead electrocardiogram showed sinus rhythm with left bundle branch block. There were diffuse negative T waves in the inferior and anterolateral leads that were concordant with the QRS complexes. Echocardiogram was normal and nuclear perfusion heart scan showed no abnormality. It was noted that the negative T waves during left bundle branch block were in the exact same leads as were the deep negative QRS complexes during ventricular pacing. The electrocardiographic changes were consistent with cardiac memory. This case is unique because cardiac memory in patients with intermittent left bundle branch block typically occurs when the QRS complexes normalize and not during left bundle branch block itself. Our findings indicate that memory Ts can develop not only after normalization of wide complex rhythms but also with alternating wide complex rhythms as in the presented case where a ventricular paced rhythm was replaced by left bundle branch block.

Rare giant T-wave inversions associated with myocardial stunning: report of 2 cases

Prominent T-wave inversions are well recognized electrocardiographic signs that can occur in acute myocardial infarction (AMI). However, the giant negative T waves may be associated with myocardial stunning without AMI.This case report describes 2 patients without AMI who developed rare giant T-wave inversions measuring up to 35 mm in depth and QT prolongation after admission to hospital. While 1 patient presented with acute pulmonary edema, the other patient presented with severe chest pain at rest and transient ST elevation.The giant T-wave inversion with QT prolongation may be caused by myocardial stunning due to the triple vessel diseases and elevated wall stress, high-end diastolic pressure and decreased coronary arterial flow during pulmonary edema in the first patient. The giant T-wave inversion with QT prolongation in the second patient may be caused by myocardial stunning due to the left anterior descending artery spasm (transient ST elevation) leading to transient total occlusion of left anterior descending artery. Percutaneous coronary intervention was successfully undergone for both patients. The patients remained well.The electrophysiologic mechanism responsible for giant T-wave inversion with QT prolongation is presently unknown. The two cases demonstrate that the rare giant negative T waves may be associated with myocardial stunning without AMI.

Effective strategies to improve the management of heart failure

The purpose of this article is to provide resources for primary care physicians to manage heart failure as a chronic disease. We review evidence-based interventions that can be adopted in primary care practices to improve adherence to available guidelines for medication use, promotion of self-care behaviors, transitions of care in acute decompensated heart failure, and end of life care. This information will be valuable to primary care providers who care for patients with heart failure in all care settings but is focused on the management of heart failure in the outpatient setting.

Giant precordial T wave inversion in a patient with gastroenteritis

Giant precordial T wave inversion (GPTI) on ECG may be the result of several pathologies, including myocardial ischemia, pulmonary edema, pulmonary embolism, subarachnoid hemorrhage, apical hypertrophy, and postpacing. We describe a case of a 75-year-old woman who developed GPTI after an episode of gastroenteritis. To our knowledge, this is the first report of this ECG pattern associated with gastroenteritis.

The pathophysiology of acute heart failure--is it all about fluid accumulation?

Despite significant advancement in chronic heart failure (HF), no breakthroughs have occurred in the last 2 decades in our understanding of the pathophysiology, classification, and treatment of acute HF (AHF). Traditional thinking, which has been that this disorder is a result of gradual fluid accumulation on a background of chronic HF, has been called into question by recent large registries enrolling less selected patient populations. It is increasingly recognized that many patients with this syndrome are elderly, have relatively preserved ejection fraction, and have mild or no preexisting chronic HF. In this review, we propose 2 primary subtypes of AHF: (1) acute decompensated cardiac failure, characterized by deterioration of cardiac performance over days to weeks leading to decompensation; and (2) acute vascular failure, characterized by acute hypertension and increased vascular stiffness. Registry data suggest that the latter is the more common form of AHF in the general population, although the former is often overrepresented in studies focused in academic tertiary care centers. Regardless of the clinical subtype, a variety of pathophysiologic mechanisms may play a role in this disorder, many of which remain poorly understood. In this review, we describe current understanding of the pathophysiology of AHF, including a critical evaluation of the data supporting both traditional and novel mechanisms, and suggest a framework for integrating these mechanisms into an overall model of AHF.

The Resting Electrocardiogram in the Management of Patients with Congestive Heart Failure: Established Applications and New Insights

The resting electrocardiogram (ECG) furnishes essential information for the diagnosis, management, and prognostic evaluation of patients with congestive heart failure (CHF). Almost any ECG diagnostic entity may turn out to be useful in the care of patients with CHF, revealing the non-specificity of the ECG in CHF. Nevertheless a number of CHF/ECG correlates have been proposed and found to be indispensable in clinical practice; they include, among others, the ECG diagnoses of myocardial ischemia and infarction, atrial fibrillation, left ventricular hypertrophy/dilatation, left bundle branch block and intraventricular conduction delays, left atrial abnormality, and QT-interval prolongation. In addition to the above well-known applications of the ECG for patients with CHF, a recently described association of peripheral edema (PERED), sometimes even imperceptible by physical examination, with attenuated ECG potentials, could extend further the diagnostic range of the clinician. These ECG voltage attenuations are of extracardiac mechanism, and impact the amplitude of QRS complexes, P-waves, and T-waves, occasionally resulting also in shortening of the QRS complex and QT interval duration. PERED alleviation, in response to therapy of CHF, reverses all above alterations. These fresh diagnostic insights have potential application in the follow-up of patients with CHF, and in their selection for implantation of cardioverter/defibrillator and/or cardiac resynchronization systems. If sought, PERED-induced ECG changes are abundantly present in the hospital and clinic environments; if their detection and monitoring are incorporated in the clinician's "routine," considerable improvements in the care of patients with CHF may be realized.

QT interval prolongation with global T-wave inversion: a novel ECG finding in acute pulmonary embolism

OBJECTIVE

The purpose of this study was to report a novel electrocardiographic (ECG) phenomenon in acute pulmonary embolism characterized by QT interval prolongation with global T-wave inversion.

METHODS

Among a total of 140 study patients with a confirmed diagnosis of acute pulmonary embolism, patients who fulfilled the inclusion criteria for QT interval prolongation with global T-wave inversion were examined. Each of these patients had undergone a detailed clinical evaluation including testing for myocardial injury and echocardiography.

RESULTS

QT interval prolongation with global T-wave inversion was found in five patients (age 51-68 years) with acute pulmonary embolism. Four were women. Acute pulmonary embolism was diagnosed by ventilation-perfusion scan in three patients and by spiral computed tomography in other two patients. None of the patients had any right or left ventricular regional wall motion abnormalities on echocardiography. All patients had changes characteristic of hemodynamically significant pulmonary embolism, including right ventricular stunning or hypokinesis and dilatation in five patients with paradoxical septal motion in four. Acute coronary syndrome was ruled out in each patient by clinical evaluation, serial ECGs and cardiac markers, and lack of regional wall motion abnormalities on echocardiography. Prolongation of QT intervals (QTc 456-521 ms) with global T-wave inversion was noted on presentation. The ECG changes gradually resolved in 1 week in all patients with appropriate treatment of acute pulmonary embolism. One patient died. None of the patients developed torsade de pointes.

CONCLUSIONS

Acute pulmonary embolism may occasionally result in reversible QT interval prolongation with deep T-wave inversion, and, thus should be considered among the acquired causes of the long QT syndrome.