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Inverted U Waves—Red Flags in Electrocardiograms

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

A patient in their 50s went to the emergency department for treatment due to intermittent compression-like pain in the chest of 1 day’s duration that lasted for several minutes each time. It occurred during activities and could be relieved after rest. The patient had a history of hypertension and diabetes for 8 years and was not regularly taking medication. When arriving at the emergency department, the patient's chest pain was relieved. Physical examination showed that their blood pressure was 181/93 mm Hg, heart rate was 81 beats per minute, respiration was 20 times per minute, and blood oxygen in indoor air was 96%; the rest of the examination yielded normal results. The patient’s 12-lead electrocardiogram (ECG) was consulted (Figure, A). About 10 minutes later, the patient's chest pain recurred, and the 12-lead ECG was repeated (Figure, B). Initial laboratory workup findings were largely unremarkable, with creatinine and high-sensitivity troponin levels all within normal limits. Serum electrolyte levels, including K+ and Ca2+, were grossly normal.

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A patient in their 50s went to the emergency department for treatment due to intermittent compression-like pain in the chest of 1 day’s duration that lasted for several minutes each time. It occurred during activities and could be relieved after rest. The patient had a history of hypertension and diabetes for 8 years and was not regularly taking medication. When arriving at the emergency department, the patient's chest pain was relieved. Physical examination showed that their blood pressure was 181/93 mm Hg, heart rate was 81 beats per minute, respiration was 20 times per minute, and blood oxygen in indoor air was 96%; the rest of the examination yielded normal results. The patient’s 12-lead electrocardiogram (ECG) was consulted (Figure, A). About 10 minutes later, the patient's chest pain recurred, and the 12-lead ECG was repeated (Figure, B). Initial laboratory workup findings were largely unremarkable, with creatinine and high-sensitivity troponin levels all within normal limits. Serum electrolyte levels, including K+ and Ca2+, were grossly normal.

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Article Information

Corresponding Author: Ding Peng, MD, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People’s Hospital, B24 Yinquan South Road, Qingyuan, Guangdong 511500, China (453000396@qq.com).

Published Online: July 31, 2023. doi:10.1001/jamainternmed.2023.1743

Conflict of Interest Disclosures: None reported.

References
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de Zwaan  C , Bär  FW , Wellens  HJ .  Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction.   Am Heart J. 1982;103(4 Pt 2):730-736.PubMedGoogle Scholar
2.
Correale  E , Battista  R , Ricciardiello  V , Martone  A .  The negative U wave: a pathogenetic enigma but a useful, often overlooked bedside diagnostic and prognostic clue in ischemic heart disease.   Clin Cardiol. 2004;27(12):674-677.PubMedGoogle ScholarCrossref
3.
Kishida  H , Cole  JS , Surawicz  B .  Negative U wave: a highly specific but poorly understood sign of heart disease.   Am J Cardiol. 1982;49(8):2030-2036.PubMedGoogle ScholarCrossref
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Gerson  MC , Phillips  JF , Morris  SN , McHenry  PL .  Exercise-induced U-wave inversion as a marker of stenosis of the left anterior descending coronary artery.   Circulation. 1979;60(5):1014-1020.PubMedGoogle ScholarCrossref
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Pérez Riera  AR , Ferreira  C , Filho  CF ,  et al.  The enigmatic sixth wave of the electrocardiogram: the U wave.   Cardiol J. 2008;15(5):408-421.PubMedGoogle Scholar
6.
Kodama-Takahashi  K , Ohshima  K , Yamamoto  K ,  et al.  Occurrence of transient U-wave inversion during vasospastic anginal attack is not related to the direction of concurrent ST-segment shift.   Chest. 2002;122(2):535-541.PubMedGoogle ScholarCrossref
7.
Kihlgren  M , Almqvist  C , Amankhani  F ,  et al.  The U-wave: a remaining enigma of the electrocardiogram.   J Electrocardiol. 2023;79:13-20.PubMedGoogle ScholarCrossref
8.
Tamura  A , Watanabe  T , Nagase  K , Mikuriya  Y , Nasu  M .  Significance of negative U waves in the precordial leads during anterior wall acute myocardial infarction.   Am J Cardiol. 1997;79(7):897-900.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 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous 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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