ECG Review-Giant T Waves
Clinical Scenario: The ECG shown in the figure was obtained from a 78-year-old woman who was being evaluated for altered mental status. How would you interpret her 12-lead tracing? What is the most likely etiology for the changes you see?
Interpretation: The rhythm is sinus at a rate of 85 beats/minute. The PR and QRS intervals are normal, but the QT interval is clearly prolonged. The axis is leftward. There is voltage for left ventricular hypertrophy (LVH). However, the most remarkable finding on this tracing is the presence of very deep and symmetric T wave inversion in multiple leads. This is the syndrome of "giant T waves." Although ischemia must clearly be considered as the possible etiology, the point to emphasize is that other entities may also produce this picture of diffusely inverted giant T waves. Among these entities are central nervsous system catastrophes (stroke, hemorrhage, Stokes-Adams attacks); non-Q wave infarction, certain types of hypertrophic cardiomyopathy, and intermittent left bundle branch block. The etiology for giant T wave inversion in these different conditions is uncertain. The patient in this case had a recent large stroke, but no evidence of infarction.
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