The differential diagnosis of conditions that produce inverted T waves is worth reviewing. It includes more than ischemia and subendocardial infarction!
Differential of T-wave inversion
1° T-wave changes
Normal variants, like juvenile T-wave pattern
CNS events (can be impressive, diffuse, and deep)
2° T-wave changes
Bundle branch blocks
Ventricular pacing (memory T-waves)
Acute pulmonary embolism (especially V1-4)
This woman presented with chest pain and shortness of breath after the stressful argument with her daughter. She was taken to the cath lab which revealed clean coronary arteries but left ventricular apical ballooning – Takotsubo cardiomyopathy.
From the differential diagnosis, there are really only four things that can produce such striking, deeply inverted T waves: coronary vasopspasm, subendocardial ischemia, CNS events (stroke or subarachnoid hemorrhage), and Takotsubo cardiomyopathy.
Hayden GE, Brady WJ, Perron AD, et al. Electrocardiographic T-wave inversion: differential diagnosis in the chest pain patient. Am J Emerg Med 20:252, 2002.
Prasad A, Lerman A, Rihad CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 155:408, 2008.