Prevalence and Prognostic Significance of T-Wave

Inversions in Right Precordial Leads of a 12-Lead

Electrocardiogram in the Middle-Aged Subjects
Aapo L. Aro, MD; Olli Anttonen, MD; Jani T. Tikkanen, BM; M. Juhani Junttila, MD;
Tuomas Kerola, MD; Harri A. Rissanen, MSc; Antti Reunanen, MD; Heikki V. Huikuri, MD
BackgroundT-wave inversion in right precordial leads V1 to V3 is a relatively common finding in a 12-lead ECG of
children and adolescents and is infrequently found also in healthy adults. However, this ECG pattern can also be the first
presentation of arrhythmogenic right ventricular cardiomyopathy. The prevalence and prognostic significance of T-wave
inversions in the middle-aged general population are not well known.
Methods and ResultsWe evaluated 12-lead ECGs of 10 899 Finnish middle-aged subjects (52% men, mean age 448.5
years) recorded between 1966 and 1972 for the presence of inverted T waves and followed the subjects for 3011 years.
Primary end points were all-cause mortality, cardiac mortality, and arrhythmic death. T-wave inversions in right
precordial leads V1 to V3 were present in 54 (0.5%) of the subjects. In addition, 76 (0.7%) of the subjects had inverted
T waves present only in leads other than V1 to V3. Right precordial T-wave inversions did not predict increased mortality
(not significant for all end points). However, inverted T waves in leads other than V1 to V3 were associated with an
increased risk of cardiac and arrhythmic death (P0.001 for both).
ConclusionsT-wave inversions in right precordial leads are relatively rare in the general population, and are not
associated with adverse outcome. Increased mortality risk associated with inverted T waves in other leads may reflect
the presence of an underlying structural heart disease. (Circulation. 2012;125:2572-2577.)
Key Words: cardiomyopathy electrocardiography epidemiology mortality T-wave inversion

-wave inversion in right precordial leads V1 to V3 of a

12-lead ECG is a common finding in children and
adolescents,1 but this electrocardiographic pattern is also
present in 0.1% to 3% of apparently healthy adults.2 4 However,
inverted T waves may mimic abnormalities in ventricular repolarization observed in patients with structural heart disease such
as arrhythmogenic right ventricular cardiomyopathy (ARVC),
which can be responsible of ventricular arrhythmias and even
sudden cardiac death.5 In ARVC, right precordial T-wave
inversions are present in 48% to 85% of patients.6 10 The use of
electrocardiographic depolarization and repolarization criteria
plays a large role in establishing the diagnosis of ARVC, and, in
the recent guidelines for the clinical diagnosis of the disease,
T-wave inversion in the right precordial leads (V1, V2, and V3)
or beyond was upgraded to a major criterion.11

Clinical Perspective on p 2577

There have been several studies on the prevalence and
clinical significance of T-wave inversions in young athletes,2,12,13 but the frequency and long-term clinical significance of inverted T waves in the general population is

unknown. Therefore, in the present study, we evaluated the

prevalence and characteristics of right precordial T-wave
inversions and other repolarization abnormalities in a large
middle-aged general population and assessed the clinical
outcome associated with these changes.

Methods
Study Population
The study population comprises of a total of 10 957 men and women
aged 30 to 59 years, who participated in the Finnish Social Insurance
Institutions Coronary Heart Disease Study (CHD Study) between
1966 and 1972. We excluded 58 subjects with unreadable or missing
ECGs, thus our final study group consisted of 10 899 subjects (52%
of whom were men, mean age 44.08.5 years) from the original
cohort. The CHD Study was a part of the larger prospective Mobile
Clinic Health Survey that was conducted in 35 populations from
different geographical areas in Finland with varying mortality rates
representing the middle-aged Finnish population. The population
groups consisted of either the whole population or a random sample
of the population of a geographical area, and the overall participation
rate of the invited population was 89.6%. A detailed account of the
study rationale and procedures performed at the baseline examination has been described previously.14 In brief, a standard 12-lead

Received November 30, 2011; accepted March 27, 2012.

From the Division of Cardiology, Department of Medicine, Helsinki University Central Hospital, Helsinki (A.L.A.); Department of Internal Medicine,
Paijat-Hame Central Hospital, Lahti (O.A., T.K.); Institute of Clinical Medicine, Department of Internal Medicine, University of Oulu, Oulu (J.T.T.,
M.J.J., H.V.H.); National Institute for Health & Welfare, Helsinki, Finland (H.A.R., A.R.).
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.
112.098681/-/DC1.
Correspondence to Aapo L. Aro, MD, Division of Cardiology, Department of Medicine, Helsinki University Central Hospital, Haartmaninkatu 4, PL
340, 00029 HUS, Helsinki, Finland. E-mail aapo.aro@helsinki.fi
2012 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org

DOI: 10.1161/CIRCULATIONAHA.112.098681

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T-Wave Inversions in General Population

2573

ECG was recorded and blood pressure, body mass index, and serum
cholesterol were measured. Before the examination, the subjects
completed a questionnaire regarding their history of previous diseases, drug therapy, and smoking habits, which was then checked
and completed, if necessary, by a specially trained nurse at the
examination. All symptoms of cardiovascular disease were documented during the examination.

Follow-Up
From the baseline examination between 1966 and 1972, the subjects
were followed for a mean of 3011 years until the end of 2007.
After a median follow-up time of 6 years, a reexamination of most of
the subjects was performed between 1973 and 1976. Less than 2% of
the subjects were lost to follow-up as a result of moving abroad, but,
for the vast majority of even this group, the survival status could be
determined. The mortality data were obtained from the Causes of
Death Register maintained by Statistics Finland, and the death
certificates were obtained for each deceased. Death from cardiac
causes was determined based on the relevant International Classification of Diseases codes. To identify cases of sudden death from
arrhythmia, all deaths from cardiac causes were reviewed by the use
of hospital records and necropsy reports, if available, based on the
definitions presented in the Cardiac Arrhythmic Pilot Study,15 as
described by our group previously.16 All episodes of congestive heart
failure, ventricular arrhythmias, and coronary artery disease serious
enough to require hospitalization were obtained from the Finnish
Hospital Discharge Register, which includes nationwide data on all
inpatient episodes in Finland at an individual level.17

ECG Measurement
A standard 12-lead ECG was recorded with the subject at rest in a
supine position at paper speed of 50 mm/s and calibration of 1
mV/10 mm. The presence or absence of bundle branch block and left
ventricular hypertrophy according to the Sokolow-Lyon criteria was
assessed, and QT-interval (corrected for heart rate according to
Bazett formula) was measured at the time of baseline examinations.
Later, all baseline ECGs were independently reevaluated by 5
physicians for the presence of inverted T waves (T wave negative by
0.1 mV or more in leads other than aVR, aVL, III, and V1). In
addition, QRS duration, ST-segment elevation in leads V1 to V3, and
terminal activation duration (longest value in leads V1 through V3
from the nadir of the S wave to the end of all depolarization) were
measured. All ECGs with inverted T waves in leads V1 through V3
were double checked, and the presence of T-wave inversions and
epsilon waves was established by consensus. Epsilon wave was
defined as a distinct deflection after the end of the QRS complex.18
For the majority of subjects, an additional ECG was taken after a
median of 6 years from the baseline examination, and the persistence
of precordial T-wave inversions was assessed.

Figure 1. ECG of a 31-year-old woman presenting typical mildly

inverted T waves in right precordial leads V1 to V3. She was still
alive 40 years later at the end of the survey. Paper speed is
50 mm/s.

individuals, only minor (0.2 mV) right precordial T-wave

inversions were present, and in 36 (67%) individuals T-wave
amplitude was between 0.2 mV and 0.4 mV. Only 2
subjects had deep negative T waves between 0.5 mV and
0.9 mV, and giant negative T waves with amplitude of
1.0 mV or less were present in 2 subjects. ST-segment was
elevated at least 1 mm at QRS-ST junction (J point) in right
precordial leads in 9 (17%) of the subjects with T-wave
inversion in these leads. In 32 (59%) individuals with right
precordial T-wave inversion, inverted T waves were present
also in lead V4 or beyond. Examples of ECGs with inverted
T waves in V1 to V3 only, and with T-wave inversions in
leads other than V1 to V3 are presented in Figures 1 and 2,
respectively. More examples of T-wave inversions are presented as online-only Data Supplement Figures I through IV.
Only 1 subject with T-wave inversions in leads V1 to V3
had prolonged terminal activation duration 55 ms, and he
was the only one having a duration of QRS complex 110

Statistical Analysis
All continuous data are presented as meansSD. The general linear
model was used to compare the age- and sex-adjusted mean values
for continuous variables and the prevalence of categorical variables
between the groups. Primary end points were all-cause mortality,
cardiac mortality, and arrhythmic death, and secondary end points
were hospitalization because of congestive heart failure, ventricular
arrhythmias, or coronary artery disease. The hazard ratios and 95%
confidence intervals for death and hospitalization were calculated by
uses of Cox proportional hazards model, with adjustments for age and
sex, subjects without T-wave inversions serving as the reference group.
KaplanMeier survival curves were plotted for T-wave inversions in
leads V1 to V3 and other leads and were compared by means of the
log-rank test. The statistical analyses were performed with SAS software, version 9.1.3 (SAS Institute) and with the Statistical Package for
Social Studies, version 14.0 (SPSS). A probability value of 0.05 was
considered to indicate statistical significance.

Results
ECG Characteristics
Inverted T waves in right precordial leads V1 to V3 were
observed in 54 (0.5%) of the subjects. In 14 (26%) of these

Figure 2. ECG of a 49-year-old man presenting mild T-wave

inversions in leads V4 to V6 only. He died of myocardial infarction during the follow-up. Paper speed is 50 mm/s.

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May 29, 2012

Table. Baseline Characteristics of Subjects

Males, %*
Age, y
Current smoker, %
Cholesterol, mmol/L
BMI, kg/m2
Heart rate, bpm
Systolic blood pressure, mm Hg
Diastolic blood pressure, mm Hg
Chronotropic medication, %
Cardiovascular disease, %
Electrocardiographic LVH, %
QTc duration. ms
QRS duration, ms
History of prior myocardial infarction, %
History of angina pectoris, %

P Value

No TWI
n10 734

TWI V13
n54

TWI Other
n76

TWI V13

TWI Other

52.4
44.08.5
34.0
6.501.31
25.93.8
7615
13821
8212
4.2
7.9
31.4
40827
878
1.1
2.3

12.9
43.68.4
34.1
6.561.78
26.04.4
6913
13522
809
2.3
14.1
23.7
40831
876
0.4
0.0

60.4
49.37.6
39.2
6.641.77
26.74.7
7617
14826
8716
19.3
30.0
39.2
40835
9011
0.0
0.6

0.001
0.77
0.98
0.72
0.94
0.001
0.18
0.18
0.48
0.08
0.22
0.93
0.86
0.63
0.17

0.17
0.001
0.30
0.36
0.08
0.95
0.001
0.001
0.001
0.001
0.13
0.98
0.001
0.19
0.34

Plus-minus values are meansSD. Subjects with no TWI serve as the comparison group for P values. To convert the values of
cholesterol to milligrams per deciliter, divide by 0.02586. TWI indicates T-wave inversion; LVH, electrocardiographic left ventricular
hypertrophy according to the Sokolow-Lyon criteria; QTc, QT corrected for heart rate.
*Adjusted for age.
Adjusted for sex.
Adjusted for age and sex.

ms in the right precordial leads. The same subject was also

the only one with an epsilon wave (online-only Data Supplement Figure V), and thus fulfilled 2 major criteria of ARVC
according to the new modification of the Task Force Criteria
(repolarization abnormality demonstrated by inverted precordial T waves and depolarization abnormality exhibited by
epsilon wave and prolonged terminal activation duration),
which is sufficient for the diagnosis of the disease.11
The baseline characteristics of the subjects with inverted T
waves in leads V1 to V3 are shown in the Table. Inverted right
precordial T waves were present in 47 women (0.9% of all
women) and 7 men (0.1% of all men) in the study population.
These subjects had lower heart rate, but no difference in age,
smoking, blood pressure, medication, left ventricular hypertrophy, or cardiovascular disease was observed between the 2
groups. A second ECG measurement a median of 6 years
after the baseline visit was available for 52 (96%) of the 54
subjects with right precordial T-wave inversions in the initial
ECG. Inverted T waves were still present in 41 (79%) of the
ECGs. Four of these subjects had T-wave inversions only in
V1 to V2, and 23 had inverted T waves also in V4 or beyond.
Overall, 130 subjects (1.2%) had inverted T waves present
in either frontal or precordial ECG leads. Seventy-six of these
individuals had T-wave inversions only in leads other than V1
to V3. These subjects were older, had a higher blood pressure,
and were more likely to have a suspected cardiovascular
disease such as hypertension, valve disease, or heart insufficiency, or to be on medication than the rest of the population.
They also had a longer duration of QRS complex, but no
differences in cholesterol levels, body mass index, smoking,
or history of coronary artery disease were present (Table).
Complete right bundle branch block (RBBB) was present
in 33 (0.3%) of the subjects, and, in 3 subjects with RBBB,

T-wave inversions continued also beyond V3. Although this

represents a minor criterion for the diagnosis of ARVC, all
the subjects with bundle branch block or preexcitation were
excluded from further analysis.

Risk of Death and Hospitalization

During the follow-up (mean follow-up 3011 years) 6133
subjects (56.5%) died. Death from cardiac causes occurred in
1969 individuals (32.1% of all deaths), and 795 (40.4%) of
these were classified as sudden arrhythmic deaths. No additional mortality was associated with right precordial T-wave
inversions in V1 to V3. In this group, 25 subjects (46%) died
during the follow-up. Nine of these deaths were due to
cardiac causes, and 2 were classified as sudden arrhythmic
deaths. The age and sex adjusted relative risk (RR) of death
was 0.95 (95% CI, 0.64 1.41; P0.81), RR for cardiac
mortality 1.18 (95% CI, 0.612.27; P0.63), and RR for
sudden arrhythmic death 0.76 (95% CI, 0.19 3.06; P0.69)
in these subjects in comparison with the subjects without
T-wave inversions. When the subjects with inverted T waves
also in V4 or beyond (n32) were considered separately, no
difference in cardiac or overall mortality was associated with
more widespread precordial inverted T waves either. Kaplan
Meier curves for all-cause mortality and cardiac mortality in
subjects with T-wave inversions are shown in Figure 3.
When all subjects with T-wave inversions only in leads
other than V1 to V3 (n76) were analyzed separately, an
increase in mortality was observed. In this group, 59 subjects
(78%) died during the follow-up. Thirty-one of these deaths
were due to cardiac causes, and 14 were classified as sudden
arrhythmic deaths. RR for all-cause mortality was 1.65 (95%
CI 1.28 2.14; P0.001), RR for cardiac mortality 2.65 (95%
CI, 1.86 3.78; P0.001), and RR for sudden arrhythmic

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Aro et al

Figure 3. KaplanMeier survival plots for overall mortality (A)

and cardiac mortality (B) in subjects with T-wave inversion in
right precordial leads V1 to V3 (TWI V1V3) and T-wave inversion
in leads other than V1 to V3 (TWI other). These subjects are
compared by log-rank analysis with subjects without inverted T
waves (No TWI). TWI indicates T-wave inversion.

death 3.16 (95% CI, 1.86 5.36; P0.001) in these subjects.

RBBB was not associated with an increased mortality.
During the long follow-up, no excess of episodes of hospitalization due to congestive heart failure, ventricular arrhythmias,
or coronary artery disease was observed in subjects with inverted
T waves in V1 to V3. However, the subjects with inverted T
waves in leads other than V1 to V3 had an increased risk of
hospitalization as a consequence of congestive heart failure (RR
2.19; 95% CI, 1.44 3.33; P0.001) and coronary artery disease
(RR 1.70; 95% CI, 1.19 2.42; P0.007).

Discussion
Inverted T waves in precordial leads beyond V1 are common
in children, but usually these T waves become upright after
pubertal development.19 However, in some healthy individuals, similar juvenile inverted T waves persist into adulthood.4
Therefore, incidentally observed T-wave change in an asymptomatic subject poses a clinical problem, because T-wave
inversions can also be the expression of an underlying cardiac
disease capable of causing sudden cardiac death.5,20 The present
study is the first to directly address the characteristics and

T-Wave Inversions in General Population

2575

prognosis of T-wave inversions at the population level. Inverted

T waves in right precordial leads V1 to V3 were present in 0.5%
of the middle-aged population, but additional features suggestive
of ARVC, such as epsilon wave or prolonged duration of
terminal QRS activation in the right precordial leads, were
extremely rare. The prognosis associated with right precordial
T-wave inversion was good and did not differ from the rest of
the population. However, inverted T waves in leads other than
V1 to V3 predicted adverse outcome.
In previous studies, the prevalence of inverted T waves in
precordial leads V1 to V3 has varied depending on the subjects
studied and the criteria used to define T-wave inversion. This
ECG pattern is more common in women, especially in younger
age groups, and appears to be present in 1% to 3% of young
adults.4,13 However, in an old cohort of 67 375 presumably
healthy men, any type of T-wave changes were present in only
0.86% of these individuals, and precordial T-wave inversions
represented only a small minority of these changes.3 In another
study that assessed the prevalence of T-wave inversions in
adolescent athletes, T-wave inversions beyond V2 were present
in only 0.1% of the subjects 16 years of age.2 In trained
athletes, a broad range of abnormal patterns may be present in
the 12-lead ECG and mimic ECG changes seen in structural
heart diseases.21 However, in a recent study, distinctly abnormal
repolarization patterns were found only in 1% of a large
population of young athletes, and more than one-third of these
subjects had evidence of structural heart disease or developed a
cardiomyopathy during follow-up.12 In another study of asymptomatic children with T-wave inversion at preparticipation
screening, diagnosis of cardiomyopathy was made in only 2.5%
of the subjects with abnormal ECG.22
In the present study, the overall prevalence of inverted right
precordial T waves was 0.5% in this 30- to 59-year-old population. This is somewhat lower than what is reported in some
previous studies, probably because of exclusion of the youngest
age groups, in which juvenile inverted T waves are more
prevalent. In most of the cases, T waves were only mildly
inverted (13 mm), and deeply inverted T waves (5 mm or
more) in V1 to V3 were present in only 0.03% of the subjects.
Only in 20% of the subjects having T-wave inversions on the
initial ECG, inverted T waves were normalized in the control
ECG taken a median of 6 years later. Therefore, it seems that this
repolarization abnormality is in most cases a constant finding,
and not due to, eg, hyperventilation, or transient emotional or
other stimuli causing increased sympathetic activity.2325 Especially in trained athletes, inverted T waves in right precordial
leads are often associated with early repolarization, which is
traditionally regarded as a benign ECG phenomenon.21 However, only 20% of the subjects in our study population with
T-wave inversions in V1 to V3 had early repolarization pattern in
these leads. An interesting novel finding was also the sex
difference in the prevalence of inverted T waves (0.9% in
women and 0.1% in men). The reason for this phenomenon is
unclear, but it may be related to different levels of sympathetic
activation or female hormones.
Although T-wave inversions in right precordial leads are
occasionally found in asymptomatic individuals, they may also
imply the presence of a heart disease such as hypertrophic
cardiomyopathy, myocardial ischemia, or ARVC.5,20 The esti-

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May 29, 2012

mated prevalence of right precordial T-wave inversions in

patients with ARVC has been reported to be up to 85% in
advanced forms of the disease,6 the extent of inverted T waves
reflecting the degree of right ventricular involvement.26 However, in a recent study of newly diagnosed patients with
suspected ARVC, inverted T waves limited to V1 to V3 were
present in only 16% of the subjects, and 32% of the subjects had
right precordial T-wave inversions extending beyond V3.10
Abnormalities in repolarization and depolarization observed in a
standard 12-lead ECG play a pivotal role in the diagnosis of
ARVC. The repolarization abnormalities are early and sensitive
markers of the disease, and inverted right precordial T waves
seem to demonstrate the most optimal sensitivity and specificity
for identifying these patients.9 Therefore, in the recently proposed modification of the Task Force Criteria for the clinical
diagnosis of ARVC, T-wave inversion in leads V1 to V3 was
upgraded as major criteria, and T-wave inversion in V1 to V2 or
V4 to V6 was upgraded as minor criteria in the repolarization
category. Furthermore, in the presence of complete RBBB,
according to these new guidelines, inverted T waves beyond V3
represent a minor criterion in the repolarization category.11 In the
present population, these extensive T-wave inversions were rare
and were observed only in 10% of the subjects with RBBB.
In the category of depolarization abnormalities for diagnosing
ARVC, epsilon wave in the right precordial leads is considered
a major and prolonged terminal activation duration 55 ms a
minor criterion. The prevalence of an epsilon wave ranges
between 8% and 33% in ARVC patients.6,27 In contrast, an
epsilon wave is a rare finding in the general population. In young
Korean men, epsilon wave was present in 0.05%.28 In our study,
only 1 subject had an epsilon wave, and the same subject had
also T waves inverted in right precordial leads, thus fulfilling the
ECG criteria for the diagnosis of ARVC. The estimated prevalence of ARVC in the general population has been ranging from
1 in 1000 to 1 in 5000.29 31 Nevertheless, mutations that may
predispose to ARVC are more prevalent in the population, and it
has been estimated that up to 1 of 200 Finns carries such a
mutation,32 suggesting a low penetrance of this mutation. Based
on the results of the present study, however, no exact estimations
of the prevalence of ARVC phenotype in the Finnish population
can be made, because no further diagnostic procedures besides
the 12-lead ECG were performed to diagnose the disease. In
addition to lack of increased mortality of subjects with T-wave
inversions in V1 to V3, the hospitalization due to congestive
heart failure or ventricular arrhythmias was not more common
among these subjects, suggesting that this ECG pattern observed
here in middle-aged subjects is probably not an early sign of
ARVC.
Although T-wave inversions in V1 to V3 was a benign finding
in the present middle-aged population, inverted T waves in other
leads carried 2-fold risk of cardiac and sudden arrhythmic
death, and predicted hospitalization due to congestive heart
failure or coronary artery disease. It is well recognized that
T-wave changes can be present in a variety of different circumstances affecting the heart and homeostasis of the body. These
conditions include ischemia, ventricular hypertrophy, cardiomyopathies, myocarditis, certain drugs, electrolyte abnormalities,
hyperventilation, and sympathetic simulation.1,33 Presence of
coronary artery disease was rare in the present population, but

the diagnosis was based only on past medical history and clinical
examination. Besides, echocardiography was not generally
available at the time of baseline examination, and therefore some
of the subjects with inverted T waves might have had a structural
cardiac disease not evident during the clinical examination, but
yet caused repolarization abnormalities in their 12-lead ECGs.
Another limitation of the present study is the relatively small
number of subjects with right precordial T-wave inversions,
which precludes definitive conclusions on the prognostic significance of this ECG pattern.
In summary, right precordial T-wave inversion in leads V1
to V3 is a relatively rare finding in the middle-aged general
population, especially in men. Although this electrocardiographic pattern can raise a suspicion of a cardiomyopathy, in
the absence of deeply inverted T waves or other features
suggestive of heart disease, right precordial T-wave inversions appear to carry normal prognosis in the general population. In contrast, inverted T waves in other than right
precordial leads may imply an underlying cardiac pathology
and are associated with increased cardiac mortality.

Sources of Funding
The study was supported by a special federal grant for Paijat-Hame
Central Hospital, and by scholarships from Onni and Hilja Tuovinen
Foundation, the Finnish Medical Foundation, and Sigrid Juselius
Foundation (HVH), Helsinki, Finland.

Disclosures
None.

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CLINICAL PERSPECTIVE
T-wave inversion in right precordial leads V1 to V3 is a common finding in a 12-lead ECG of children and adolescents,
and is sometimes present in healthy adults, as well. However, right precordial T-wave inversion can also be the first
manifestation of a structural heart disease such as arrhythmogenic right ventricular cardiomyopathy. In the present study,
we assessed the prevalence and prognostic significance of T-wave inversions in a large Finnish middle-aged general
population cohort with a long follow-up. Inverted T waves in right precordial leads V1 to V3 were present in 0.5% of the
subjects, but deeply inverted T waves (5 mm or more) or additional features suggestive of arrhythmogenic right ventricular
cardiomyopathy were extremely rare. The prognosis associated with right precordial T-wave inversion was good and did
not differ from the rest of the population. However, T-wave inversions in leads other than V1 to V3 were associated with
a significantly increased risk of cardiac and arrhythmic death. Thus, although inverted T waves in V1 to V3 can raise a
suspicion of a cardiomyopathy, in the absence of deeply inverted T waves or other features suggestive of a heart disease,
this ECG pattern does not predict adverse outcome. In contrast, T-wave inversions in other than right precordial leads may
reflect the presence of an underlying cardiac pathology and are associated with increased mortality.

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Prevalence and Prognostic Significance of T-Wave Inversions in Right Precordial Leads of

a 12-Lead Electrocardiogram in the Middle-Aged Subjects
Aapo L. Aro, Olli Anttonen, Jani T. Tikkanen, M. Juhani Junttila, Tuomas Kerola, Harri A.
Rissanen, Antti Reunanen and Heikki V. Huikuri
Circulation. 2012;125:2572-2577; originally published online May 10, 2012;
doi: 10.1161/CIRCULATIONAHA.112.098681
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2012 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539

The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circ.ahajournals.org/content/125/21/2572

Data Supplement (unedited) at:

http://circ.ahajournals.org/content/suppl/2012/04/23/CIRCULATIONAHA.112.098681.DC1.html

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SUPPLEMENTAL MATERIAL

Figure 1 (Supplement Data).

Electrocardiogram of a 46-year-old female with mild right precordial T-wave inversions in
V1-3 extending into leads V4 to V6. She died of non-cardiac causes at the age of 77.

aVR

II

aVL

V3

V4

aVF
III

V1

V5

V2
V6

Figure 2 (Supplement Data).

Electrocardiogram of a 51-year-old male with inverted T-waves in right precordial leads V1 to
V3 associated with ST-segment elevation and electrocardiographic left ventricular
hypertrophy. He died of non-cardiac causes at the age of 75.

aVR

II

aVL

III

aVF

V3

V4

V5

V1

V2

V6

Figure 3 (Supplement Data).

Electrocardiogram of a 44-year-old female with giant inverted T-waves in all precordial leads,
electrocardiographic LVH and deep q-waves in inferior leads. She died of myocardial
infarction 17 years later.

aVR

V3

II

aVL

V4

III

aVF

V5

V1

V2

V6

Figure 4 (Supplement Data).

Electrocardiogram of a 45-year-old male with T-wave inversions in other than right precordial
leads V1-3 associated with electrocardiographic LVH and strain. He died of myocardial
infarction nine years later.

II

aVR
V3

aVL
V4

III

aVF

V1

V2

V5

V6

Figure 5 (Supplement Data).

12-lead ECG of a male subject with inverted T-waves and epsilon wave (arrow) in leads V1V3 thus fulfilling two major criteria of ARVC diagnosis. He also had prolonged TAD

55ms,

and duration of QRS complex over 110ms in the right precordial leads. The subject died of
cardiac causes at the age of 67 years.