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Giant T-wave Inversion in an Older Patient With Sudden Loss of Consciousness

To identify the key insights or developments described in this article
1 Credit CME

A patient in their 60s with a history of long-term uncontrolled hypertension presented to the emergency department reporting left hip pain and reduced mobility owing to a fall 2 days prior. A hip fracture was suspected, and external fixation and skin traction were performed after admission to the orthopedics department. In the early morning of day 2 after admission, the patient suddenly lost consciousness. A 12-lead electrocardiogram (ECG) was immediately performed; its findings are shown in Figure, A. For comparison, the findings of an ECG performed before admission are shown in Figure, B. The patient’s high-sensitivity cardiac troponin-I serum level was 0.21 µg/L (reference, <0.023 µg/L). Findings of a neurologic examination showed bilateral pupil size, 2.5 mm; right limbs, unresponsive to pain stimuli and with hypotonia; all limbs, reduced tendon reflex; and bilateral Babinski reflex, negative. Acute myocardial infarction was suspected, and a cardiologist was consulted.

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As early as 1954, Burch and colleagues1 reported giant T-wave inversions in patients with severe cerebrovascular events such as subarachnoid hemorrhage and acute ischemic stroke. In 2001, Hurst and colleagues2 named the inversion Niagara Falls−like T wave because of its similarity to the shape of the waterfalls. The mechanisms underlying these apparent T-wave changes were postulated to be related to myocardial ischemia caused by severe coronary artery spasm in the context of sympathetic storming after severe cerebrovascular events.3 The major ECG characteristics of Niagara Falls−like T wave are (1) deep T-wave inversion of more than 10 mm—in some cases, more than 20 mm; (2) occurring in precordial leads (V4-V6) and possibly in limb leads; (3) transient and usually vanishing within a few days; (4) asymmetric; (5) without prominent ST-segment deviation and no pathologic Q wave; (6) pronounced Q-T interval prolongation; (7) U wave greater than 0.15 millivolt; and (8) sometimes accompanied by ventricular arrhythmias.4

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Article Information

Corresponding Author: Fengguang Kang, MD, Guangzhou University of Chinese Medicine, No. 12 Jinsha Rd, Daliang Town, Shunde District, Foshan, Guangdong 528000, China (kmonmon@163.com).

Published Online: March 20, 2023. doi:10.1001/jamainternmed.2022.6618

Conflict of Interest Disclosures: Dr Kang reported support from the Key Medical Talents Training Project of Shunde District, Foshan, China (No. 202211001). No other disclosures were reported.

References
1.
Burch  GE , Meyers  R , Abildskov  JA .  A new electrocardiographic pattern observed in cerebrovascular accidents.   Circulation. 1954;9(5):719-723. doi:10.1161/01.CIR.9.5.719 PubMedGoogle ScholarCrossref
2.
Lindberg  DM , Jauch  EC .  Images in cardiovascular medicine: neurogenic T waves preceding acute ischemic stroke.   Circulation. 2006;114(9):e369-e370. doi:10.1161/CIRCULATIONAHA.106.616821 PubMedGoogle ScholarCrossref
3.
Cruickshank  JM , Neil-Dwyer  G , Stott  AW .  Possible role of catecholamines, corticosteroids, and potassium in production of electrocardiographic abnormalities associated with subarachnoid haemorrhage.   Br Heart J. 1974;36(7):697-706. doi:10.1136/hrt.36.7.697 PubMedGoogle ScholarCrossref
4.
Hurst  JW .  Interpreting Electrocardiograms: Using basic principles and vector concepts (fundamental and clinical cardiology). Taylor & Francis; 2001.
5.
Wagner  GS , Macfarlane  P , Wellens  H ,  et al; American Heart Association Electrocardiography and Arrhythmias Committee.  Council on Clinical Cardiology; American College of Cardiology Foundation; Heart Rhythm Society. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part VI acute ischemia/infarction.   Circulation. 2009;119(10):e262-e270. doi:10.1161/CIRCULATIONAHA.108.191098PubMedGoogle ScholarCrossref
6.
Hancock  EW , Deal  BJ , Mirvis  DM ,  et al; American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; American College of Cardiology Foundation; Heart Rhythm Society.  AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V electrocardiogram changes associated with cardiac chamber hypertrophy.   Circulation. 2009;119(10):e251-e261. doi:10.1161/CIRCULATIONAHA.108.191097 PubMedGoogle ScholarCrossref
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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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