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Journal of Electrocardiology 49 (2016) 596 – 602
www.jecgonline.com
Original research
Differences between cardiac memory T wave changes after idiopathic left
ventricular tachycardia and ischemic T wave inversion induced by acute
coronary syndrome
Takashi Nakagawa, MD, a, b,⁎ Tetsuo Yagi, MD, PhD, a Akihiko Ishida, MD, a
Yoshiaki Mibiki, MD, PhD, a Yoshihiro Yamashina, MD, PhD, a Hirokazu Sato, MD, PhD, a
Eiji Sato, MD, a Juri Komatsu, MD, a Yoshifumi Saijo, MD, PhD b
a
Division of Cardiology, Sendai City Hospital, Sendai, Japan
b
Graduate School of Biomedical Engineering, Tohoku University, Sendai, Japan

Abstract Background: Cardiac memory (CM) after idiopathic left ventricular tachycardia (ILVT) mimics
ischemic T wave inversion (TWI) induced by acute coronary syndrome (ACS). We aimed to
establish electrocardiography criteria for differentiating the CM from ischemic TWI.
Methods and results: We evaluated 16 ILVT and 48 ACS patients. We identified TWI after ILVT in 9/
16 patients (CM group), typically in leads II, III, aVF, aVR, and V4–6. The characteristics of CM were
similar to TWI induced by ACS involving right coronary artery, but the CM group had more TWI in V4
and shorter QTc. The criteria of (1) positive T in aVL, (2) negative or isoelectric T in II, and (3) negative T
in V4–6 or (4) QTc b 430 ms were 100% sensitive and 96% specific for the CM group.
Conclusion: CM after ILVT can be differentiated in most cases from ischemic TWI by the
distribution of TWI and the QTc.
© 2016 Elsevier Inc. All rights reserved.

Keywords: Cardiac memory; T wave inversion; Idiopathic left ventricular tachycardia; Ischemic T wave; T wave axis

Introduction features have been reported for differentiating these two

conditions.
Cardiac memory (CM) is a phenomenon characterized by
Shvilkin et al. reported ECG criteria that enabled
transient T wave changes that appears on the resumption of a
differentiation between the CM after right ventricular apical
normal ventricular activation pattern after a period of
pacing and the TWI due to non-ST-elevation myocardial
abnormal ventricular activation, such as ventricular pacing,
infarction [7]. They used the key attribute of CM: a T wave
bundle branch block, Wolf–Parkinson–White syndrome, or
axis in sinus rhythm approaching the direction of the
ventricular tachycardia (VT) [1,2]. Verapamil-sensitive
abnormal QRS complex [1]. ILVT has a QRS complex that
idiopathic left ventricular tachycardia (ILVT) is a common
is characterized by right bundle branch block (RBBB) and
form of VT in a structurally normal heart [3,4]. However, the
left axis deviation (left posterior fascicular type). Thus, we
CM after ILVT mimics the ischemic T wave inversion (TWI)
hypothesized that the T wave axis on the frontal plane and
induced by an acute coronary syndrome (ACS) [5,6]. Since
the precordial TWI pattern of the CM after ILVT would be
CM itself does not require therapy, differentiation between
different from those induced by ACS.
the CM and the TWI caused by ACS is important. Patients
The aims of this study were to investigate the character-
with ILVT sometimes complain of chest pain, making it
istics of the CM after termination of ILVT and to establish
difficult to exclude ACS based solely on a clinical history in
ECG criteria that could differentiate the CM after ILVT from
the emergency department (ED). Thus, unnecessary exam-
the TWI induced by ACS.
inations might be performed. However, no diagnostic

⁎ Corresponding author at: Takashi Nakagawa MD, Division of Methods

Cardiology, Sendai City Hospital, 1-1-1 Asuto Nagamachi, Taihaku-ku,
Sendai, Miyagi, 982-8502, Japan. This was a retrospective, observational study in a single
E-mail address: nakadi31415@yahoo.co.jp emergency medical care center in Japan. The study was
http://dx.doi.org/10.1016/j.jelectrocard.2016.04.001
0022-0736/© 2016 Elsevier Inc. All rights reserved.
 T. Nakagawa et al. / Journal of Electrocardiology 49 (2016) 596–602
approved by the Sendai City Hospital ethics committee.
Written informed consent from individual patients was not
required under Japanese law, because this study was purely
observational.
Patients in the ILVT and CM groups
Sixteen consecutive patients with left posterior fascicular
type ILVT who underwent radiofrequency ablation between
April 2006 and May 2013 at Sendai City Hospital were
analyzed retrospectively (ILVT group). We evaluated TWI
on the ECG during sinus rhythm after the termination of the
clinical VT, and defined the TWI as CM. The ILVT group
was divided into two subgroups: the CM group and the
non-CM group. We compared the duration, heart rate, and
QRS axis on the frontal plane of the clinical VT, as well as
other ECG characteristics, between these two groups. We
defined the duration of ILVT as the time from the onset of
palpitations, chest pain, or chest discomfort to termination of
the clinical VT in the ED.
Since all CM disappeared without any therapy, we used
the ECG without CM as a control. In the CM group, we
evaluated the QRS axis on the frontal plane of ILVT, the T
wave axis on the frontal plane of the CM, and the QRS and T
wave axes on the frontal plane of the control ECG.
Patients in the ACS group
The group of patients with ACS were retrospectively
selected from 75 consecutive patients who had ACS with
ischemic TWI, identified within 72 h after emergency
percutaneous coronary intervention (PCI) at Sendai City
Hospital between January 2010 and December 2012. ACS
was defined as ST-elevation myocardial infarction (STEMI),
non-STEMI, or unstable angina pectoris [8]. Patients with a
prior history of myocardial infarction, atrioventricular block
or ventricular pacing rhythm, atrial fibrillation, left main
trunk or multivessel PCI, left ventricular hypertrophy with
ST-T change on the ECG, left bundle branch block, or
frequent ventricular ectopy were excluded from the ACS
group. If TWI was present on N 1 ECG within 72 h after PCI,
the ECG used for analysis was the one that had TWI in the
most leads. The culprit coronary artery lesion was deter-
mined by a high-volume interventional cardiologist at the
time of PCI on the basis of a coronary artery occlusion or
stenosis N 75%, by visual estimation that was consistent with
the clinical and ECG data. The ACS group was divided into
three subgroups based on the culprit lesion: left anterior
descending artery (LAD), left circumflex artery (LCX), or
right coronary artery (RCA).
We compared the T wave axis on the frontal plane, the
lead distribution of TWI, the QTc interval, and other ECG
characteristics between these three ACS groups and the CM
group as potential parameters indicative of CM. We then
determined which ECG criteria were able to differentiate the
CM group from the ACS groups.
ECG analysis
A standard 12-lead ECG was recorded at a paper speed of
25 mm/s and a voltage of 10 mm/mV. The tracings were
597
analyzed manually without magnification. All ECGs were
analyzed by a single investigator who was blinded to the
patient group allocation.
T wave amplitude was measured by ruler in each lead from
the T wave peak/nadir to the baseline determined by the T–P
segment. In the case of biphasic T waves, the most negative
deflection was measured and all were classified as negative [7].
The T wave was classified as isoelectric if both positive and
negative components were present with an amplitude
b 0.05 mV. We defined TWI as negative or isoelectric T
waves in leads I, II, III, aVL, aVF, or V1–6, or the presence of a
positive or isoelectric T wave in lead aVR. TWI in two or more
contiguous leads was considered significant.
ST elevation or depression was defined as an elevation or
depression of N 0.1 mV at the J-point in two or more
contiguous leads. ST elevation or depression of N 0.1 mV at
the J-point in aVR was also considered significant. The QT
interval was measured manually over three consecutive RR
intervals in lead II. The corrected QT interval (QTc) was
calculated according to Bazett's formula for each of the
three, and the results were then averaged [7]. The mean QRS
and T wave axes on the frontal plane were determined
manually using the hexaxial reference system derived from
the Einthoven triangle. The algebraic sum of the Q, R, and S
wave or T wave amplitudes in leads I and III was used to plot
the axis [9–11].
Statistical analysis
Continuous variables are expressed as mean ± SD or
median with range, and categorical variables as numbers and
percentages. We compared continuous variables using
Student's t-test or the Mann–Whitney U-test, depending
on their distribution. We compared categorical variables
using the chi-square test when appropriate; otherwise, we
used Fisher's exact test. Statistical analyses were performed
using SPSS version 22.0 (IBM, USA). A P-value b 0.05 was
considered significant.
Results
Prevalence of CM after ILVT
The mean age of the ILVT group was 35 ± 17 years and
14/16 (88%) were male. All cases of clinical VT had a QRS
complex with RBBB and left axis deviation, and the VT was
terminated or slowed down by verapamil. If the VT was
slowed down but not terminated, cardioversion was performed
in the ED.
We identified TWI due to CM after termination of ILVT
in 9/16 (56%) patients (CM group). Fig. 1 shows a typical
example of CM after ILVT. In the CM group, echocardiog-
raphy (n = 9), coronary angiography (n = 2), coronary
computed-tomography angiography (n = 1), exercise stress
test (n = 1), and cardiac magnetic resonance imaging (n = 2)
were performed, but no patient had evidence of ischemic
heart disease or structural heart disease. All cases of CM
disappeared within six weeks without any therapy.
598 T. Nakagawa et al. / Journal of Electrocardiology 49 (2016) 596–602

Fig. 1. Observed T wave changes induced by cardiac memory after termination of idiopathic left ventricular tachycardia (ILVT). A. ECG of ILVT; the QRS
complex of the ILVT was negative in leads I, II, III, aVF and V3–6, and positive in aVR. B. Cardiac memory after ILVT; the T wave after ILVT was negative in
leads I, II, III, aVF and V3–6, and positive in aVR. C. Control ECG; cardiac memory disappeared after six weeks.

Comparison of the characteristics between the CM and the
non-CM group
Table 1 shows the clinical and ECG characteristics of the
CM and non-CM group. The duration of ILVT was longer in
the CM group (median 16 h vs. 2 h, P = 0.007). The heart
rate of the ILVT in the CM group tended to be faster, but the
difference was not significant (201 ± 21 vs. 178 ± 26/min,
P = 0.063). The control ECG of the CM group had minor
abnormalities – incomplete right bundle branch block,
negative T wave in lead III or V1 – which did not differ
from the non-CM group.
QRS axis on the frontal plane of ILVT and shift of T wave
axis on the frontal plane in the CM group
On the control ECG in the CM group, the mean QRS axis
on the frontal plane was + 68 ± 16°, and the mean T wave axis
on the frontal plane was + 45 ± 17° (normal axis, Fig. 2). In
contrast, the mean QRS axis on the frontal plane of ILVT in the
CM group was − 89 ± 15° (range − 65° to − 114°; left axis
deviation). Thus, after termination of the ILVT, the mean T
wave axis on the frontal plane shifted from +45 ± 17° to −65 ±
26° (range −30° to −103°; left axis deviation), comprising the
CM.

Table 1 ACS group selection

Clinical and ECG characteristics of the cardiac memory (CM) and non-CM
group. A total of 75 patients underwent PCI for ACS, 27 patients
Group CM (n = 9) non-CM (n = 7) P-value were excluded because of a prior history of myocardial
Age 31 ± 12 42 ± 21 0.20 infarction (n = 7), atrioventricular block or ventricular
Male, n (%) 7 (78) 7 (100) 0.30 pacing rhythm (n = 7), atrial fibrillation (n = 6), PCI for
Duration of ILVT (hours) 16 (2–48)† 2 (1–5)† 0.007 left main trunk or multivessel disease (n = 3), left ventricular
Heart rate of ILVT (/min) 201 ± 21 178 ± 26 0.063 hypertrophy with ST-T change on the ECG (hypertrophic
QRS axis of ILVT (°) − 89 ± 15 − 93 ± 6 0.56
cardiomyopathy or severe aortic valvular stenosis, n = 2),
Abnormality of control ECG:
IRBBB, n (%) 1 (11) 1 (14) 0.70 left bundle branch block (n = 1), or frequent ventricular
Negative T in lead V1, n (%) 3 (33) 1 (14) 0.39 ectopy (n = 1). Forty-eight patients who developed ischemic
Negative T in lead III, n (%) 1 (11) 2 (29) 0.40 TWI within 72 h after emergency PCI made up the ACS
Mean ± SD, except for † median (range). ILVT – idiopathic left ventricular group. The mean age of the ACS group was 63 ± 13 years
tachycardia; IRBBB – intermittent right bundle branch block. and 33/48 (69%) were male. Based on the culprit lesion, the
 T. Nakagawa et al. / Journal of Electrocardiology 49 (2016) 596–602 599

Fig. 2. QRS and T wave axes on the frontal plane in the cardiac memory (CM) group.

ACS group was divided into three subgroups: LAD group LAD group had a T wave axis on the frontal plane around −120°
(n = 27), LCX group (n = 10), and RCA group (n = 11). and an isoelectric T in aVL, but no patient had a positive T in
aVL. On the other hand, all RCA group patients were in this
Comparison of the characteristics among the ACS and the range. The mean T wave axes on the frontal plane of the CM
CM groups group and RCA group were − 65 ± 26° and − 54 ± 9.8° (P =
0.29).
Table 2 shows the clinical and ECG characteristics of the
We also compared the TWI in the precordial leads (Table 3).
patients in the ACS (LAD, LCX, and RCA) and CM groups.
TWI in the RCA and LCX group was commonly present in V5–6
Patients in the CM group were significantly younger and did not
but rarely in V4. The difference between the CM and RCA/LCX
have abnormal Q waves. ST depression and elevation did not
groups in the presence of TWI in V4 was statistically significant
differ significantly between the CM and ACS groups. QTc
(7/9 vs. 2/11, P = 0.01, and 7/9 vs. 2/10, P = 0.02, respectively).
intervals were significantly shorter in the CM group and 5/9
patients in the CM group had normal QTc intervals (b 430 ms). ECG criteria for differentiating CM after ILVT from ischemic
TWI induced by ACS
Lead distribution of TWI and T wave axis on the frontal
plane in the ACS and CM groups We posed the following criteria: (1) positive T in aVL, (2)
negative or isoelectric T in II, and (3) negative T in leads V4–6.
The TWI due to CM was commonly present in leads II, All patients in the CM group, but none in the LAD group, met
III, aVF, aVR and V4–6 (Table 3). The T wave axis on the criteria (1) and (2) (Table 3). All patients in the RCA group and
frontal plane of the CM was left axis deviation and ranged 6/10 in the LCX group also met criteria (1) and (2), but only
from − 30° to − 103° (Fig. 3). A T wave axis on the frontal
plane in this range means that lead aVL has a positive T and Table 3
lead II has a negative or isoelectric T. In the range from − 30° Lead distribution of T wave inversion in the acute coronary syndrome (ACS)
to − 120° (gray shaded area in Fig. 3), we compared the and cardiac memory (CM) groups.
number of patients between the CM group and the three ACS Lead ACS CM
groups. The difference between the CM and LAD/LCX LAD LCX RCA
(n = 9)
groups was statistically significant (9/9 vs. 2/27, P b 0.001, (n = 27) (n = 10) (n = 11)
and 9/9 vs. 4/10, P b 0.001, respectively). Two patients in the I 21 (78)† 6 (60) 0 2 (22)
II 9 (33)† 7 (70) 11 (100) 9 (100)
Table 2 III 10 (37)† 7 (70) 11 (100) 9 (100)
Clinical and ECG characteristics of the acute coronary syndrome (ACS) and aVR 16 (59) 4 (40) 8 (73) 7 (78)
cardiac memory (CM) groups. aVL 24 (89)† 4 (40) 0 0
Group ACS CM aVF 10 (37)† 7 (70) 11 (100) 9 (100)
(n = 9) V1 10 (37) 1 (10) 1 (9) 1 (11)
LAD LCX RCA
V2 24 (89)† 1 (10) 1 (9) 2 (22)
(n = 27) (n = 10) (n = 11)
V3 26 (96)† 1 (10) 1 (9) 3 (33)
Age 64 ± 12† 63 ± 11† 58 ± 11† 31 ± 12 V4 26 (96) 2 (20)† 2 (18)† 7 (78)
Male, n (%) 18 (67%) 7 (70%) 8 (73%) 7 (78%) V5 22 (81) 8 (80) 10 (91) 7 (78)
Abnormal Q wave, n (%) 18 (67%)† 5 (50%)† 9 (82%)† 0 V6 15 (56) 8 (80) 10 (91) 7 (78)
ST depression, n (%) 8 (30%) 3 (30%) 3 (27%) 5 (56%) (aVL + II) 0 6 (60) 11 (100) 9 (100)
ST elevation, n (%) 14 (52%) 3 (30%) 3 (27%) 3 (33%) (aVL + II) + (V4–6) 0 0 1 (9) 7 (78)
QTc, ms 541 ± 83† 505 ± 48† 521 ± 59† 429 ± 57
n, (%). †P b 0.05 compared with CM group.
Mean ± SD, †P b 0.05 compared with CM group. LAD – left anterior (aVL + II) means positive T wave in aVL and negative or isoelectric T wave
descending; LCX – left circumflex; RCA – right coronary artery; QTc – in lead II. (V4–6) means negative T wave in leads V4–6.
corrected QT interval. Abbreviations as in Table 2.
600 T. Nakagawa et al. / Journal of Electrocardiology 49 (2016) 596–602
Fig. 3. Distribution of T wave axis on the frontal plane in the left anterior
descending artery (LAD), left circumflex artery (LCX), and right coronary
artery (RCA) groups and the cardiac memory (CM) group.The frontal plane
axes were assumed to be separated by 30° outside the black circle. Black
dots show the values of the T wave axis on the frontal plane in the acute
coronary syndrome (ACS) group (from the outside of the circle, LAD, LCX,
and RCA). White dots show the values of the T wave axis on the frontal
plane in the CM group. The gray-shaded area indicates the range from − 30°
to − 120° (left axis deviation).
one of these patients met criterion (3) (Table 3). The
combination of (1), (2), and (3) was 78% sensitive and 98%
specific for the CM group.
Two patients in the CM group had no TWI in precordial
leads and did not meet criterion (3). These two patients had a
normal QTc interval. In the ACS group who met criteria (1)
and (2), only two patients had a normal QTc interval.
Therefore, we added criterion (4) QTc b 430 ms. The criteria
(1), (2), and (3) or (4) were 100% sensitive and 96% specific
for the CM group.
Fig. 4 summarizes these diagnostic steps. Fig. 5 shows
examples of the TWI induced by ACS and by CM after ILVT.
Discussion
In this study, we presented a detailed ECG analysis of the
CM after termination of ILVT. The main finding of this
study was that the ECG criteria of (1) positive T in aVL, (2)
negative or isoelectric T in II, and (3) negative T in V4–6 or
(4) QTc b 430 ms were 100% sensitive and 96% specific in
differentiating the CM group from the ACS group. These
criteria were based on the attributes of the CM and the area of
ischemia as described below.
The T wave axis on the frontal plane of CM approaches
the direction of the abnormal QRS complex [1]. The QRS
complex of ILVT shows left axis deviation. Thus, the T
wave of CM also showed left axis deviation, that ranged
from − 30° to − 103° in this study (Figs. 2, 3). In this range,
aVL has a positive T and II has a negative or isoelectric T.
Many patients in the LAD group and about half in the LCX
group had a negative T in aVL because of lateral ischemia.
Fig. 4. The diagnostic steps for differentiating cardiac memory (CM) from
ischemic T wave inversion.Figures indicate the number of cases showing the
T wave changes and QTc interval in both groups.
Therefore, we derived criteria (1) and (2). However, since the
T wave axis on the frontal plane of CM was similar to that of
inferior ischemia, these criteria failed to exclude the RCA
group and some of the LCX group.
In the precordial leads, the T wave of CM also changes to
the same direction as the abnormal QRS complex [1].
Because the QRS complex of ILVT has an RBBB
morphology, the QRS of lead V1 is usually positive, whereas
the QRS of leads V4–6 are usually negative. Therefore, the
negative T wave due to CM was commonly in V4–6 (Table 3).
The RCA and LCX groups had a negative T in II, III, aVF, and
V5–6, because of infero-lateral ischemia, but rarely in V4.
Furthermore, other patients in the ACS group had a negative T
in V4–6 due to severe lateral ischemia or anterior-lateral
ischemia, but they also had a negative T in aVL and did not
meet criterion (1). This led us to derive criterion (3). According
to this theory, CM after ILVT usually has a positive T in V1 [5].
The criterion of a positive T in V1 is useful to exclude the
anterior ischemia in the LAD group (Table 3). However, since
criteria (1) and (2) already excluded the LAD group, we did not
use the latter criterion in this study.
Two patients in the CM group had no TWI in the precordial
leads. These patients met criteria (1) and (2), but their T wave
axis on the frontal plane showed mild left axis deviation (− 30°
and − 49°) compared with the QRS axis on the frontal plane of
their ILVT (− 87° and − 90°) and their CM disappeared within
a few days. We considered that their CM had not reached a
steady state [12]. The T wave changes due to CM are known to
accumulate with an increased duration of abnormal QRS and
heart rate [13]. For example, CM develops for one day as a
result of right ventricular apical pacing at physiologic rates, but
does not reach a steady state (short-term CM). It needs more
than one week to reach a steady state (long-term CM) [12].
Previous studies created long-term CM with right ventricular
pacing and examined its characteristics [7,12–14]. In this
study, CM was induced by a clinical episode of ILVT and we
could not control the duration. Therefore, some patients in the
 T. Nakagawa et al. / Journal of Electrocardiology 49 (2016) 596–602 601

Fig. 5. ECGs of T wave inversion induced by acute coronary syndrome (ACS) and those by cardiac memory (CM) after idiopathic left ventricular tachycardia
(ILVT). A-1 ACS involving the left anterior descending artery (#7); lead aVL does not have a positive T. A-2 CM of ILVT; this ECG meets criteria (1), (2), and
(3). A-3 ILVT; the QRS complex of ILVT is slightly negative in V1, and the CM of ILVT (A-2) has a negative T in V1. This case is rare. B-1 ACS involving the
right coronary artery (#2); this ECG meets criteria (1) and (2), but V4 has a positive T and QTc is prolonged. B-2 CM of ILVT; this ECG meets the criteria (1), (2),
and (3). B-3 ILVT; a typical case of ILVT showing right bundle branch block and left axis deviation.

CM group would not have reached long-term CM. It has been
reported that QTc is not prolonged in short-term CM [12,14].
These two patients in the CM group had short-term CM and
normal QTc intervals. Accordingly, we derived criterion (4)
for short-term CM after ILVT.
In the ED, the use of these criteria can improve the
differential diagnosis of these two conditions by using a
standard ECG, avoiding unnecessary examinations such as
coronary angiography.
Study limitations
This study has some limitations. First, this was a small,
single-center study and we derived the ECG criteria based on
a retrospective analysis of ECGs. Further large studies are
required in order to prospectively validate the actual
accuracy of the criteria proposed here. Second, we excluded
ACS patients with multivessel disease, prior history of
myocardial infarction, left ventricular hypertrophy, etc. The
ECG criteria are not able to differentiate all the types of
ischemic heart disease we encounter in the clinical setting.
Third, TWI induced by ACS is a broad term encompassing
diverse conditions (Wellens' syndrome, reperfusion T wave
inversion, T wave inversion in complete MI, and so forth). In
the ACS group of this study, 39/48 (81%) patients had STEMI
and 32/48 (67%) patients had Q-wave infarction. Therefore,
further studies including only non-STEMI and unstable angina
pectoris are required to improve the clinical significance of the
ECG criteria presented here. Finally, we analyzed only the left
posterior fascicular type of verapamil-sensitive ILVT. We
602 T. Nakagawa et al. / Journal of Electrocardiology 49 (2016) 596–602
could not use the criteria for the left anterior fascicular type
(QRS complex with right axis diversion) and upper septal
fascicular type (QRS complex with normal axis) because the T
wave axis on the frontal plane of their CM would not be left
axis deviation.
Conclusions
Long sustained ILVT leads to CM after its termination. The
T wave axis on the frontal plane, TWI pattern in the precordial
leads, and QTc intervals are useful in the differential diagnosis
of the T wave changes induced by ACS.
Funding
None.
Conflict of interest
None declared.
Acknowledgements
We presented this study in part at the 35th Annual
Scientific Session of the Heart Rhythm Society, San
Francisco, California, in May 2014.
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