Background: Despite no objective definition, hyperacute T waves (HATW) are recommended by the American College of Cardiology as a STEMI equivalent finding, requiring emergent reperfusion.
Objective: We sought to derive and validate a quantitative definition of HATW.
Methods: We retrospectively evaluated adults with possible ACS across five PCI centers. Exclusions were: lack of pre-angiogram ECG, QRS duration ≥110 ms, and elevated troponin without angiogram. The outcome definition was: myocardial infarction with TIMI 0-1 flow culprit lesion. ECG measures included T wave magnitude (T wave area relative to QRS amplitude) and symmetry (T wave peak-to-end time relative to onset-to-peak time). The HATW score was derived and evaluated on separate groups. The primary analysis was HATW score performance for acute coronary occlusion in patients without STEMI criteria.
Results: 3,274 patients were reviewed, and 618 were excluded. 1,261 and 1,395 patients were allocated to derivation and validation groups. In derivation, the optimal HATW score threshold for $98% specificity was 2 consecutive leads with mean HATW score $0.7. In validation, the performance for acute coronary occlusion in the subset without STEMI criteria (N = 1,300) was 98.4% specificity, 20.7% sensitivity, 47.4% positive predictive value, and 12.54 positive likelihood ratio. Among patients without STEMI criteria but positive HATW score, 84% had a culprit lesion causing acute myocardial infarction.
Conclusion: The HATW score is the first objective definition of HATW showing significant clinical utility as an ECG finding of acute coronary occlusion in potential acute coronary syndrome patients.
JACC: Advances Editor-in-Chief
Candice K. Silversides, MD, FACC
JACC: Advances CME Editor
Kenneth A. Ellenbogen, MD
Author
H. Pendell Meyers, MD
Important Dates
Date of Release: October 22, 2025
Term of Approval/Date of CME/MOC Expiration: October 21, 2026