Clinical implications of transient and persistent T-Wave inversion after STEMI

Background

T-wave inversion (TWI) frequently occurs after ST-segment elevation myocardial infarction (STEMI) and reflects myocardial injury and recovery. Persistent TWI has been associated with adverse prognosis; however, the clinical significance of transient TWI remains unclear. In particular, data linking TWI trajectories to left ventricular (LV) reverse remodeling on long-term echocardiographic follow-up are limited.

Purpose

To investigate the association between post-infarction TWI trajectories and changes in LV systolic function and regional wall motion, as well as clinical outcomes, in patients with STEMI.

Methods

We retrospectively analyzed patients with STEMI who underwent percutaneous coronary intervention between January 2020 and December 2024. Among them, 158 patients who underwent follow-up echocardiography and electrocardiography (ECG) between 6 months and 2 years after the index event were included.

Based on serial ECGs, patients were classified into three groups: no TWI; transient TWI, defined as TWI present on early follow-up ECG but resolved on subsequent ECG; and persistent TWI, defined as TWI persisting on long-term follow-up ECG. The median timing of early follow-up ECG was 38 days (interquartile range 29.5–43.0 days). Changes in left ventricular ejection fraction (LVEF) and wall motion score index (WMSI) were compared. Clinical outcomes were assessed using landmark analysis from the time of the final follow-up ECG.

Results

Of the 158 patients, 35 had no TWI, 95 transient TWI, and 28 persistent TWI. Baseline clinical characteristics were largely comparable; however, infarct size and baseline LV function differed. Peak high-sensitivity troponin I levels were lowest in the no TWI group and higher in the transient and persistent TWI groups (59,981 ± 46,125 vs. 86,357 ± 43,946 vs. 85,706 ± 43,435 ng/L; p = 0.017). Baseline LVEF was lowest in the persistent TWI group (47 ± 8% vs. 50 ± 9% vs. 54 ± 10%; p = 0.002).

During follow-up, the transient TWI group showed the greatest improvement in LVEF and WMSI, whereas the persistent TWI group demonstrated limited recovery (p = 0.009 and p = 0.002, respectively). Landmark analysis showed no significant difference in clinical outcomes among groups (p = 0.22), although persistent TWI was associated with a numerically lower event-free survival.

Conclusion

In STEMI patients, TWI trajectory is closely associated with LV functional recovery. Transient TWI is linked to favorable reverse remodeling, whereas persistent TWI reflects impaired myocardial recovery. TWI trajectory appears to be a marker of myocardial recovery rather than an independent predictor of long-term clinical outcomes.Changes in LVEF and WMSI by TWIFor image description, please refer to the figure legend and surrounding text.Clinical outcomes according to TWIFor image description, please refer to the figure legend and surrounding text.