14/05/2025
Right precordial T-wave inversion: Differentiating ACS and PE
With increasing awareness of the ECG changes of Wellens syndrome in recent years, it is easy for premature closure to occur in the diagnostic process with the above presentation. In patients with symptoms of ACS and right precordial T-wave inversion, we must always consider acute RV strain as a differential in addition to ischaemia/infarction.
The finding of associated T-wave inversion in leads III and V1 has demonstrated a high specificity (99%) for differentiating PE from ACS. When right precordial T-wave inversion is present, the clinician should be prompted to look for other ECG features suggestive of RV dilatation, including clockwise rotation and right axis deviation. In patients where clinical suspicion for PE is high, right precordial T-wave inversion may be a useful marker of severity, associated with massive PE and high pulmonary pressures.
