ECGWeekly

Our goal is to make ECG interpretation simple, practical, and fun for acute providers; and we believe that mastery of this simple skill will save lives.

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T-wave alternans: bigger, smaller, bigger, smaller. 🔎

Upright or inverted doesn’t matter—it’s the beat-to-beat change in size.

Spot it, and you’ve spotted a patient at very high risk of torsades.

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📷 The T-wave size.

Bigger, smaller, bigger, smaller, beat to beat. Upright or inverted doesn’t matter.

It’s different from electrical alternans, and it flags a patient at very high risk of torsades. 📷

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Electrical alternans: the QRS changes size beat to beat. 🫀

In T-wave alternans, what changes from one beat to the next?

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MYTH VS. REALITY? 🤔

Sgarbossa and modified Sgarbossa are accepted in the 2022 ACC/AHA chest pain guidelines.

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Don’t rely on a long QT to predict torsades. ⚠️

The QT is often prolonged, but T-wave alternans is a far stronger predictor.

Long QT: fix the electrolytes and watch closely.
T-wave alternans: torsades may be minutes away.

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T-wave alternans can be an ominous warning: bigger, smaller, bigger, smaller from beat to beat. ⚠️

Dr. Mattu explains why this pattern deserves serious attention when you’re worried about impending torsades.

Would you recognize it in time?
https://t.co/lSsocVXJ8E

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The Aslanger pattern isn’t in the formal ACC/AHA guidelines. It’s been described in the interventional cardiology literature.

Dr. Mattu’s tip: if you’re worried, share that literature with your cardiologist so they know what you’re talking about. 🔎

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TRUE OR FALSE? 🤔

The Aslanger pattern is part of the formal ACC/AHA STEMI guidelines.

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A 45 yo m presents to the emergency department with palpitations. He has no known history of coronary artery disease. He is alert, with a systolic blood pressure of approximately 120 mm Hg and a heart rate near 180 beats/min. The following ECG shows.......https://t.co/oRwvrVBmci

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✅ It’s looking for ST elevation in two contiguous leads. Lead III alone won’t meet that rule.

But isolated ST elevation in III can be part of the Aslanger pattern, linked to acute coronary occlusion. Don’t let “nonspecific” end the read. 🔎

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ST elevation in lead III. None in II or aVF. 🫀

The computer reads it as nonspecific.

Why might it miss this?

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Don’t dismiss isolated ST elevation in lead III. ⚠️

Your computer is looking for two contiguous leads—so check V1 vs V2 and the lateral leads yourself.

It may be the Aslanger pattern: acute RCA or circumflex occlusion without traditional STEMI criteria.

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Chest pain. ST elevation in lead III only. ST in V1 higher than V2. Lateral ST depression with upright T waves. 🔎

Computer: nonspecific.

Nonspecific—or acute occlusion?

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71M with chest pain. Lead III has ST elevation—but II and aVF don’t. 👀

The computer called it nonspecific. Cardiology: not a STEMI.

But the ED physician recognized a subtle high-risk pattern.

What did he see?
https://t.co/zyMixwlgAw

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MYTH ❌Before calling AFib, confirm:
No clear P waves marching through
The rhythm is irregularly irregular
Don’t let “irregular” end the interpretation.

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MYTH OR REALITY? 👀

Any irregular rhythm without obvious P waves is atrial fibrillation.

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A 76-year-old man presents with chest pain suggestive of acute coronary syndrome. An initial 12-lead ECG is obtained and shown below, but does not meet conventional STEMI criteria......https://t.co/v1GpwHsZhC

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Grouped beats ≠ automatically AFib. 🔎

Map the P waves:
Regular → Mobitz
Premature → PACs

The rhythm may be hiding in the atria.

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The computer says AFib—but the beats occur in repeating groups. 🔎

What should you map next?

The P waves.

Regular → think Mobitz
Premature → think PACs

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