Hyperacute T waves

Hyperacute T waves are tall, broad based and more symmetrical than normal. There is no absolute size that is too tall to be normal, as it depends on the size of the QRS. It has been suggested that a T:QRS ratio greater than 0.33 in V1-4 is abnormal. A T/R ratio has also been described. T waves in V4-6 should never be taller than the R wave. If in doubt, compare with a previous baseline ECG.

Hyperacute T waves can be the first sign of coronary occlusion. They localise to the affected artery distribution and can have reciprocal changes. They may also occur with Prinzmetal angina, or when the ST segments are on the way back down again after reperfusion.

See also: T and U waves

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What's the difference between peaked and hyperacute T waves?

Before we move on to other skills, it is very important that you can tell the difference between the peaked T waves of hyperkalemia and the hyperacute T waves of acute ischemia. Both of these signs feature large T waves but they are subtly different:

  • Peaked T waves have a sharp point and a narrow base.
  • Hyperacute T waves have a broader base and are 'fatter' so that there is more area under the curve.

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Tall T waves
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  • ECG Library (81)

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    In the ECGquest archives, this ECG has been tagged with: - Chest pain 12-Lead Anterior ST depression Hyperacute T waves Acute Anterior MI Dr Smith's ECG Blog CC BY-NC
    A 40 year old man with chest pain since last night

    This ECG is from a man in his 40s who presented with chest pain since the previous evening, associated with vomiting and diaphoresis. He had recently stopped smoking.

    This ECG shows subtle disproportionately tall T waves in V2-V3 and ST depression in V3-6 with slight ST elevation in V1. The cause was a 100% proximal LAD thrombotic occlusion.

    In the ECGquest archives, this ECG has been tagged with: - Chest pain 12-Lead Hyperacute T waves Acute Anterior MI Dr Smith's ECG Blog CC BY-NC
    A patient with chest pain that is resolving. Computer interprets ED ECG as completely Normal.

    This ECG is from a man in his 60s who presented with resolving chest pain.

    This ECG shows hyperacute T waves in V2-4. The cause was an 80% obstruction of the LAD with a large thrombus. An earlier ECG showed ST segment elevation.

    In the ECGquest archives, this ECG has been tagged with: - 12-Lead Hyperacute T waves Acute Anterior MI Acute Inferior MI Dr Smith's ECG Blog CC BY-NC
    The computer and the cardiologist called this a “Normal EKG”

    This ECG is from a woman in her 40s who presented with 'heartburn' overnight and then worsening chest pain 1 hour prior to arrival.

    This ECG shows subtle MI with inferior and anterior hyperacute T waves and some reciprocal ST depression in aVL. The cause was a complete occlusion of a wraparound LAD.

    In the ECGquest archives, this ECG has been tagged with: - 12-Lead Anterior ST elevation Hyperacute T waves Inferior ST depression Lateral ST depression Acute Anterior MI Dr Smith's ECG Blog CC BY-NC
    A man in his sixties with chest pain at midnight with undetectable troponin

    This ECG is from a man in his 60s who presented with 3 hours of chest pain.

    This ECG shows ST elevation and hyperacute T waves in V2 with inferior and lateral ST depression. The cause was acute LAD occlusion.

    In the ECGquest archives, this ECG has been tagged with: - Chest pain 12-Lead Anterior ST elevation Hyperacute T waves Acute Anterior MI Dr Smith's ECG Blog CC BY-NC
    A 50-something male with acute chest pain

    This ECG is from a man in his 50s who presented with chest pain and diaphoresis.

    This ECG shows anterior ST elevation and hyperacute T waves due to 100% LAD occlusion.

    In the ECGquest archives, this ECG has been tagged with: - Chest pain 12-Lead Anterior ST elevation Hyperacute T waves Dr Smith's ECG Blog CC BY-NC
    What happens when you don’t recognize an OMI?

    This ECG is from a man in his 60s who presented with chest pain.

    This ECG shows hyperacute T waves and anterior ST elevation that evolved to cardiogenic shock due to a left main occlusion.

    In the ECGquest archives, this ECG has been tagged with: - 12-Lead De Winter T waves Hyperacute T waves Acute Anterior MI Dr Smith's ECG Blog CC BY-NC
    Doctor, should we activate the hospital’s “STEMI alert”?

    This ECG is from a woman in her 50s who presented with chest pain.

    This ECG shows hyperacute T waves with de Winter's pattern in V3-5, due to a 100% proximal occlusion of the LAD.

    In the ECGquest archives, this ECG has been tagged with: - Chest pain Dyspnoea 12-Lead Hyperacute T waves Acute Anterior MI Dr Smith's ECG Blog CC BY-NC
    How long would you like to wait for your Occlusion MI to show a STEMI? Sometimes serial ECGs minimizes the delay.

    This ECG is from an elderly woman who presented with acute chest pain and shortness of breath.

    This ECG shows sinus rhythm with minimal ST elevation in V1-3 and hyperacute T waves in V2. Serial ECGs evolved to a clear STEMI. The cause was a 100% mid-LAD occlusion.

    In the ECGquest archives, this ECG has been tagged with: - Chest pain Dyspnoea 12-Lead Hyperacute T waves Septal ST elevation Mid-anterior MI Dr Smith's ECG Blog CC BY-NC
    The delay between OMI and STEMI claims yet another patient’s anterior wall

    This ECG is from an elderly woman who presented with chest pain and shortness of breath.

    This ECG shows ST elevation in V2 with hyperacute T waves in V2-3. Even though this does not meet STEMI criteria, it is highly suspicious. Serial troponins did rise, pain was ongoing and the ECG evolved to meet STEMI criteria. A 100% mid-LAD occlusion was found to be the cause. Echo showed widespread wall motion abnormalities and reduced ejection fraction.

    In the ECGquest archives, this ECG has been tagged with: - Chest pain 12-Lead Anterior ST elevation Hyperacute T waves Late R wave transition Pathological Q waves Premature ventricular complex Acute Anterior MI Dr Smith's ECG Blog CC BY-NC
    What happens when a patient with LAD OMI does not go immediately to the cath lab?

    This ECG is from an elderly woman who presented with chest pain.

    This ECG shows ST elevation V2-4 with poor R progression and hyperacute T waves. The cause was an acute LAD occlusion.

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