Hyperacute T wave in Precordial Leads

A 61-year old male presented to our ER with 6 hours left sided chest pain associated with sweating. Pain occurred at midnight at 1am. He was a known case of HTN, type 2-DM and CAG nine months ago showed 70% stenosis in obtuse marginal branch (small vessel) and minor plaque in mid LAD. He was on regular medications including 75mg Aspirin.

On arrival he had minimal chest discomfort. Vitals were within normal limits. ECG taken showed Normal Sinus Rhythm with no ST-T changes. 

However, repeat ECG taken 1 hour later during chest pain showed SR with Hyperacute T waves in anterior leads.

So, is it Anterior STEMI?

Three differentials come when there is hyperacute T wave in precordial leads.

1. Hyperkalemia

2. Early repolarization

3. Anterior wall STEMI

LVH may also lead to tall T waves.

In this ECG, hyperkalemia is ruled out since T wave is not tented, QRS duration is normal. Later on his serum K level was normal.

In early repolarization, R wave amplitude should be tall. But in our case, the R-wave amplitude is very small (V1-V3).

He was taken to the cath-lab and CAG revealed 95% thrombotic occlusion in the mid LAD which was stented with a DES.

His follow-up ECG next day showed SR with minimal ST elevation and T wave inversion in anterior leads. (?Reperfusion T waves). There was no q waves.

He had an uneventful course of hospitalization and discharged 3 days later.