EKGs are a simple, cheap modality that can give an emergency physician quite a bit of information.  Sometimes, in a busy ER, this information can be very subtle and almost overlooked without a second thought. A perfect example of this is a New Tall T-wave in  lead V1 (NTTV1). This finding can be a normal variant, but can also be a precursor to badness.

What is a NTTV1?

  • While a normal EKG has a flat or inverted T-wave in lead V1, a NTTV1 can be an early sign of an ischemic hyperacute T-wave
  • Upright T-wave in lead V1 is abnormal if:
  1. Height of upright T-wave in V1 taller than T-wave in V6, or
  2. NEW, upright T-wave in V1 (compare to old EKG)

What are the causes of a NTTV1?

  • Ischemia (CAD)
  • LVH
  • LBBB
  • High Left Ventricular Voltage (Young Athletes)
  • Lead Misplacement

What is the significance of NTTV1?1

  • 84.4% of patients in a series of 218 patients undergoing cardiac catheterization had severe CAD (>75% stenosis)
  • In patients with one vessel disease and NTTV1 >0.15mV, the lesion was:
  1. Left circumflex artery disease (44%)
  2. Right coronary artery (22%)
  3. Left anterior descending artery (2%)
  • In patients with two vessel disease and NTTV1 >0.15mV, the lesions were:
  1. Left circumflex and right coronary artery disease (69%)
  2. Left anterior descending and left circumflex arteries (7%)
  3. Left anterior descending and right coronary arteries (17%)



1 Hr Post Presentation

EKGs From: Mattu A. ECG’s for the Emergency Physician 1. 2003.

Take Home Message

Assuming a patient doesn’t have LVH or LBBB, a new, upright, tall T-wave in lead V1 or a T-wave in lead V1 taller than V6 could signify hyperacute T-waves and precede acute myocardial infarction.  Remember to always compare to prior EKGs.

Manno B, Hakki A, Iskandrian A, Hare T. Significance of the upright T wave in precordial lead V1 in adults with coronary artery disease. J Am Coll Cardiol. 1983;1(5):1213-1215. [PubMed]
Salim Rezaie, MD

Salim Rezaie, MD

ALiEM Associate Editor Clinical Assistant Professor of EM and IM University of Texas Health Science Center at San Antonio Founder, Editor, Author of R.E.B.E.L. EM and REBEL Reviews