Hyperacute T Waves Are Specific for Occlusion Myocardial Infarction, Even Without Diagnostic ST-Segment Elevation (JACC: Advances October 2025)-Article: Hyperacute T Waves Are Specific for Occlusion Myocardial Infarction, Even Without Diagnostic ST-Segment Elevation

Article: Hyperacute T Waves Are Specific for Occlusion Myocardial Infarction, Even Without Diagnostic ST-Segment Elevation

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This study addresses the lack of an objective and quantitative definition for hyperacute T waves (HATWs), an important electrocardiogram (ECG) marker of acute coronary occlusion myocardial infarction (OMI), particularly in patients who do not meet traditional ST-segment elevation myocardial infarction (STEMI) criteria. The American College of Cardiology (ACC) and European Society of Cardiology (ESC) recognize HATWs as STEMI equivalents needing emergent reperfusion, yet no rigorous quantitative criteria existed previously.<br /><br />Researchers retrospectively analyzed 2,656 emergency department patients with suspected acute coronary syndrome from five international centers, excluding those with wide QRS complexes or missing data. They developed a neural network-based HATW score using measurements of T-wave magnitude (area under the T-wave relative to QRS amplitude) and symmetry (timing characteristics of the T-wave peak and end), derived from expert-annotated ECGs. The score aimed for high specificity (>98%) to reliably identify true occlusion.<br /><br />In the derivation cohort, the optimal threshold (average HATW score ≥0.7 in two consecutive leads) achieved 99.2% specificity and 27.4% sensitivity for OMI without STEMI criteria. Validation in a separate cohort showed the score maintained 98.4% specificity and 20.7% sensitivity, with a positive predictive value of 47.4%. Notably, among patients without STEMI criteria but positive HATW score, 84% had confirmed culprit lesions causing myocardial infarction. The HATW score performed comparably to STEMI criteria but identified additional OMI cases missed by traditional criteria. It outperformed simpler T-wave amplitude-based measures, underscoring the value of analyzing T-wave shape and timing.<br /><br />Clinical analysis revealed that many patients with positive HATW scores did not receive angiography within the recommended 90 minutes, indicating a gap in recognition and timely treatment. The authors emphasize that HATWs are not always a precursor to ST elevation and should be considered independently for urgent intervention. They advocate automated software integration of the HATW score for objective, reproducible identification to aid nonexperts and enhance artificial intelligence ECG interpretation.<br /><br />Limitations include retrospective design, a high-risk population limiting generalizability, and reliance on specialized software for score calculation. Further prospective validation and implementation studies are needed. Overall, this study provides the first validated, objective metric for HATWs, supporting their role as STEMI equivalent ECG findings critical for diagnosing OMI and guiding emergent reperfusion therapy.

Keywords

hyperacute T waves

HATW score

acute coronary occlusion

myocardial infarction

STEMI equivalents

electrocardiogram

neural network

T-wave morphology

emergent reperfusion

acute coronary syndrome