What is the significance of T-wave inversion in the precordial leads?

Abstract

Patient N was vacationing in the Las Vegas and winning at the blackjack table when he noticed a sudden onset of rapid heart rate and passed out. When EMTs arrived, patient was found to be in wide complex tachycardia at the rate of 140 to 160 bpm. Patient was defibrillated x1 and converted to sinus rhythm. Mr N is a healthy 36-year-old businessman without any significant medical history. He is not taking any prescription or over the counter medications. His review of systems and physical exam are unremarkable. His family history is significant for an older brother who died suddenly at the age of 35. His younger sister has been having episodes of frequent unexplained syncope but has not been evaluated yet. His subsequent evaluation included electrocardiography (ECG), laboratory studies, echocardiogram, cardiac catheterization, electrophysiology study, and cardiac MRI. The ECG in sinus rhythm showed precordial ST elevations, T-wave inversions, and epsilon waves. Echocardiogram showed normal LV and RV size and systolic function with estimated EF 60%. There were no signs of coronary artery disease on cardiac cath. The EP study was positive for inducible VT that was mapped to the RV free wall. Cardiac MRI showed marked thinning of the right ventricular myocardium and ‘‘fatty infiltration’’ in the right ventricular free wall. Patient was diagnosed with arrhythmogenic right ventricular cardiomyopathy (ARVC) and the ICD was implanted and b-blocker therapy was initiated. Genetic testing was done, results pending.