ECG Analysis - Mr. Vinoth, 28M | 15/7/2026 | HR: 92 bpm

Basic Parameters

Key Abnormality: T-Wave Inversions in Right Precordial Leads

• V1 and V2: Deep, symmetric, sharply inverted T waves
• V3: Biphasic to shallowly inverted T wave
• V4-V6, I, II, III, aVL, aVF: T waves upright and normal
• No ST elevation or depression in any lead
• No epsilon wave clearly visible (though this requires careful scrutiny - present in only 30% of ARVC cases)
• No S1Q3T3 pattern (argues against pulmonary embolism)

Differential Diagnosis (Most to Least Likely in a 28-Year-Old Male)

1. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) - HIGH PRIORITY

• T-wave inversions V1-V3 are seen in 85% of ARVC patients
• Epsilon wave (terminal QRS notch at J point) seen in 30%
• Prolonged S-wave upstroke ≥55 ms in V1-V3 seen in 95%
• Associated with sudden cardiac death in young adults, especially athletes
• Autosomal dominant inheritance - family history is key

2. Persistent Juvenile T-Wave Pattern (Benign Variant)

• Normally, T-wave inversions in V1-V3 are physiological in childhood
• In young adults (especially young Black males), this pattern can persist benignly
• Diagnosis of exclusion - ARVC must be ruled out first

3. Right Ventricular Strain (RV Strain)

• Acute pulmonary embolism or pulmonary hypertension can cause right precordial T inversions
• Usually accompanied by right axis deviation, S1Q3T3, or sinus tachycardia
• Less likely here given normal axis and rate, but worth considering if there are respiratory symptoms

4. Wellens' Syndrome (LAD Critical Stenosis)

• Deep symmetric anterior T-wave inversions can represent critical LAD stenosis even in a young patient
• Less typical distribution (Wellens usually affects V2-V4 more prominently)
• Important to consider if the patient has chest pain

5. Myocarditis

• Viral inflammation of myocardium can cause focal T-wave changes
• May present with chest pain, fever, elevated troponins

Red Flag Clinical Correlations to Ask About

Recommended Investigations

1. Echocardiogram (Echo) - FIRST priority: evaluate right ventricular size, wall motion, and function. RV dilatation or wall motion abnormality strongly supports ARVC
2. Cardiac MRI - Gold standard for ARVC; detects fibrofatty infiltration and RV structural changes
3. Troponin I/T - Elevated in myocarditis, ischemia
4. D-dimer / CT pulmonary angiogram - If PE is clinically suspected
5. Holter / 24-hour ECG monitor - Look for ventricular ectopy, VT runs, and epsilon waves
6. Exercise stress test - ARVC characteristically worsens with exercise
7. Genetic testing - If ARVC confirmed (desmosomal gene mutations in ~50% of cases)
8. Signal-averaged ECG - Can detect late potentials in ARVC

Clinical Bottom Line

Note: This is an educational ECG interpretation. Clinical decisions must be made by a qualified physician with full patient history and examination.

12-Lead ECG Analysis — Mr. Vinoth, 28M | 15/7/2026 | HR: 92 bpm

Systematic Review

Abnormal Findings

⚠️ Deep T-Wave Inversions - Right Precordial Leads

• No ST elevation or depression in any lead
• No epsilon wave clearly identified (subtle - needs signal-averaged ECG)
• No S1Q3T3 pattern (PE less likely)
• No right axis deviation
• No LVH/RVH voltage criteria met

Differential Diagnosis

1. 🔴 Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) - Must Exclude First

• T-wave inversions V1-V3 occur in 85% of ARVC patients
• Epsilon wave (terminal QRS notch) - present in only 30%, may be subtle here
• Prolonged S-wave upstroke ≥55 ms in V1-V3 - seen in 95%
• Causes fibrofatty replacement of RV myocardium
• Leading cause of sudden cardiac death in young athletes
• Autosomal dominant - family history of sudden death is critical to elicit

2. 🟡 Persistent Juvenile T-Wave Pattern (Benign Variant)

• Physiological T-wave inversions in V1-V3 normally persist in some young adults
• More common in young Black/South Asian males
• Diagnosis of exclusion only - ARVC must be formally ruled out

3. 🟡 Right Ventricular Strain

• From acute PE or pulmonary hypertension
• Less likely here - no right axis deviation, no S1Q3T3, rate nearly normal
• Consider if breathlessness, hypoxia, or recent immobility

4. 🟠 Wellens' Syndrome (Critical LAD Stenosis)

• Type B Wellens = deep symmetric anterior T inversions
• Represents threatened anterior MI from proximal LAD stenosis
• Unusual at age 28 without risk factors but must be considered with chest pain

5. 🟡 Myocarditis

• Viral myocarditis can cause focal T-wave changes
• Consider if fever, chest pain, recent viral illness, elevated troponin

Recommended Workup

Clinical Bottom Line

Restrict all strenuous physical activity and sport - exercise is a major trigger for fatal ventricular arrhythmias in ARVC.

⚕️ This interpretation is for educational purposes. A qualified physician must correlate with full clinical history, examination, and further investigations before making management decisions.