The Journal of emergency medicine · 2026
Isolated T-Wave Inversion in Lead aVL: A Diagnostic Blind Spot in Emergency Department Chest Pain Evaluation.
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Muhammad Owais, Govender Kiren
Аннотация
BACKGROUND: Isolated T-wave inversion (TWI) in lead aVL is commonly regarded as a benign normal variant in asymptomatic individuals during routine electrocardiogram (ECG) interpretation. In patients presenting with chest pain, however, this subtle abnormality may represent early high lateral myocardial ischemia, often involving diagonal branch disease, and may be overlooked when the remainder of the ECG appears normal. The diagnostic challenge in such cases is not a lack of knowledge regarding lead aVL, but the ease with which isolated abnormalities can be discounted when patients appear clinically stable, and ECGs are reviewed outside the full clinical context.
CASE REPORT: A man in his mid-60s presented to the ED with 3 h of ongoing retrosternal chest pain. He appeared clinically stable on arrival. The initial ECG demonstrated isolated TWI in lead aVL as the sole abnormality, without ST-segment deviation or additional ischemic changes. Given the persistence and typical nature of the symptoms, serial high-sensitivity cardiac troponin I levels were obtained and were markedly elevated, confirming non-ST-elevation myocardial infarction. Coronary angiography subsequently demonstrated an 80% stenosis of the first diagonal branch of the left anterior descending artery, which was successfully treated with percutaneous coronary intervention. Following revascularization, the T-wave abnormality in lead aVL resolved. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In busy emergency department settings, isolated T-wave inversion in lead aVL may be discounted when patients appear clinically stable, particularly when ECGs are reviewed rapidly or independently of the patient encounter. This case demonstrates that persistent ischemic symptoms, even in the presence of subtle and isolated ECG changes, may represent early myocardial ischemia. Careful correlation of ECG findings with ongoing symptoms and cardiac biomarker trends is therefore essential to avoid missed or delayed diagnosis of acute coronary syndrome.
CASE REPORT: A man in his mid-60s presented to the ED with 3 h of ongoing retrosternal chest pain. He appeared clinically stable on arrival. The initial ECG demonstrated isolated TWI in lead aVL as the sole abnormality, without ST-segment deviation or additional ischemic changes. Given the persistence and typical nature of the symptoms, serial high-sensitivity cardiac troponin I levels were obtained and were markedly elevated, confirming non-ST-elevation myocardial infarction. Coronary angiography subsequently demonstrated an 80% stenosis of the first diagonal branch of the left anterior descending artery, which was successfully treated with percutaneous coronary intervention. Following revascularization, the T-wave abnormality in lead aVL resolved. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In busy emergency department settings, isolated T-wave inversion in lead aVL may be discounted when patients appear clinically stable, particularly when ECGs are reviewed rapidly or independently of the patient encounter. This case demonstrates that persistent ischemic symptoms, even in the presence of subtle and isolated ECG changes, may represent early myocardial ischemia. Careful correlation of ECG findings with ongoing symptoms and cardiac biomarker trends is therefore essential to avoid missed or delayed diagnosis of acute coronary syndrome.