When the ECG Looks Dramatic – but the Heart Is Healthy

A previously healthy man in his 40s was admitted with chest pain considered atypical. The ECG showed ST elevations in aVL and in leads V2–V3, as well as ST depression in II, III, and aVF. T-wave inversions were also present in V3–V6. Despite these striking changes, the patient had preserved and tall R waves in the precordial leads.

Echocardiography revealed no regional wall motion abnormalities, and troponin was as low as 4 ng/L. Because of the pronounced ECG changes and chest discomfort, coronary angiography was performed. The coronary arteries were smooth and unobstructed. The chest pain was therefore considered non-cardiac, and the patient was discharged.

Benign T-wave inversions. ST-elevation in AVL, V2 and V3. ST-depression in inferior leads. T-wave inversions in V3-V6

Benign T-Wave Inversion – a Normal Variant

Although the ECG appeared alarming, this was a classic example of benign T-wave inversion — a normal variant most commonly observed in individuals of African ancestry.It may mimic acute coronary syndrome (ACS) but lacks the pathological features associated with myocardial ischemia or necrosis.

This phenomenon has been well described in the literature. In a 2011 study by Roukoz and Wang (Annals noninvasive electro 2011), more than 11,000 patients were evaluated. So-called benign T-wave inversion was found in 3.7% of men and 1.0% of women of African descent, in 0.7% of Asian men, but was absent among White individuals.

How to Differentiate from Pathological ECG Changes

For clinicians, distinguishing benign T-wave inversion from ischemic or inflammatory patterns is crucial. Key diagnostic features include:

1. Preserved and often tall R waves in the precordial leads. In anterior infarction (LAD territory), R-wave amplitude is typically reduced.

2. T-wave inversions in V4–V6, sometimes extending to the inferior leads, but without dynamic changes over time.

3. Mild ST elevation may be present, reflecting early repolarisation.

4. Normal troponin and no wall motion abnormalities on echocardiography.

In Wellens syndrome, representing ischemia and reperfusion in the LAD territory, T-wave inversions occur typically in V2–V3 (occasionally V4). In contrast, benign T-wave inversion are more prominent in leads (V3) V4–V6. Pericarditis usually produces diffuse ST elevation without R-wave loss but often with PR-segment depression.

Patterns of ST-elevation and Benign T-wave inversions. STTNV: Normal variant ST-elevation. ERP: Early repolarization

Pattern Recognition Is Key

Interpretation of ECGs in such cases depends heavily on pattern recognition and clinical context.An isolated ECG tracing must always be evaluated alongside clinical findings, biomarkers, and imaging results.Familiarity with normal variants — particularly across different ethnic backgrounds — is essential to prevent misdiagnosis and unnecessary invasive procedures.

Take-Home Message

• Benign T-wave inversion is a normal ECG variant, most frequently seen in men of African descent.

• It may mimic myocardial infarction but is characterised by preserved R waves, normal troponin, and absence of wall motion abnormalities.

• Always interpret ECG findings in their clinical context.

• Awareness of this pattern improves diagnostic accuracy and prevents overtreatment of patients presenting with chest pain.