French and Russian articles initially recognized the TV₁-taller-than-TV₆ pattern as abnormal. In the first English-language article on the subject, Weyn and Marriott found this pattern and no other abnormality in approximately 1% of hospital electrocardiograms (1). Diagnoses in their 80 patients were coronary heart disease in 25%, systemic hypertension in 24%, lung disease in 11%, miscellaneous conditions in 23%, and no apparent disease in 17%.

Perhaps because of the large hypertensive patient population, high blood pressure appears to be the most common disorder associated with isolated TV₁ taller than TV₆ at the Medical Center of Louisiana. Indeed, the patient whose electrocardiogram is shown in the Figure had long-standing, untreated high blood pressure averaging 155/95 mm Hg, a value he believed to be at the upper limit of normal. An echocardiogram revealed concentric left ventricular hypertrophy (wall thickness = 1.3 cm) in the absence of other abnormalities.

With advanced left ventricular hypertrophy due to systemic hypertension, the T-wave vector is anteriorly directed and the QRS vector is large and posteriorly directed, giving deep S waves and positive T waves in lead V1 and tall R waves and inverted T waves in lead V6, the so-called left-ventricular-hypertrophy-with-strain pattern. Although the QRS changes often precede the T-wave changes, such is not always the case, and anterior rotation of the T-wave vector before significant QRS changes are seen accounts for the isolated TV₁-taller-than-TV₆ pattern in hypertensive patients. Dilaveris et al recently described a decrease in T-wave amplitude in the frontal plane as an early marker of altered ventricular repolarization that may occur before QRS voltage changes in patients with systemic hypertension (2). They did not comment on horizontal-plane changes, which account for the TV₁-taller-than-TV₆ pattern. Because positioning of the precordial leads may vary from one electrocardiogram to the next, occasionally the T in V₁ is taller than that in V₆ in one electrocardiogram but not another. Thus, the pattern of TV₁ being taller than TV₆ is more convincingly abnormal when seen in more than one electrocardiogram.

Preoperative examination by an internist or cardiologist provides not only the opportunity to assess the risks of the procedure, but often the chance to evaluate and manage a variety of serious conditions not previously addressed. This patient now receives an angiotensin-converting enzyme inhibitor, and his blood pressure readings are consistently normal.

1. Weyn AS, Marriott HJL. The T-V1 taller than T-V6 pattern: its potential value in the early recognition of myocardial disease. Am J Cardiol 1962;10:764-766.
2. Dilaveris P, Gialafos E, Poloniecki J, Hnatkova K, Richter D, Andrikopoulos G, Lazaki E, Gialafos J, Malik M. Changes of the T-wave amplitude and angle: an early marker of altered ventricular repolarization in hypertension. Clin Cardiol 2000;23:600-606.