Giant T wave inversion associated with Stokes: Adams syndrome

Mohamed Ghouse Khan*

Head of ER, Kauvery Hospital-Heart City, Trichy, India



We have demonstrated here massive T wave inversion in the ECG of a patient who had a syncope- a Stoke Adams syndrome from complete heart block.


Stokes-Adams or Adams-Stokes syndrome is a periodic fainting spell in which there is intermittent complete heart block or other high-grade arrhythmias that result in loss of spontaneous circulation and inadequate blood flow to the brain.

We report here the occurrence of giant (deep and broad) T wave inversion associated with complete heart block

We wish to relate the deep, obtuse, asymmetrical, and broad waves with the loss of consciousness occurring during Stokes Adams syndrome. We believe that this specific electrocardiographic syndrome is unassociated with coronary artery disease and that several factors are involved in its causation.

Case Presentation

A 53-year-old, middle-aged female, with T2 DM for 12 years, presented to ER with complaints of spells of giddiness/transient loss of consciousness for two days. Her most recent episode of syncope was at 11:30 am on 09/01/2022, lasting for about 10 minutes. The patient was initially taken to a neurologist for evaluation of syncope. After ECG was taken, the patient was referred to Kauvery, Heart-City. No history of hypertension.

On Examination

Conscious, oriented,

CVS: S1S2 +

RS: Normal vesicular breath sounds

Abdomen: Soft


BP: 110/80 mmHg, HR: 44 bpm, SpO2: 98%

GRBS: 115 mg/dl


The patient was initially evaluated, serial ECG’s were done


Fig. 1. ECG was taken OUTSIDE Kauvery Hospital.


Fig. 2. ECG was taken in Heart City emergency of Kauvery Hospital.


Fig. 3. Post PPI ECG.


Good LV function. No Regional wall motion abnormalities


ECG showed a complete heart block with massive T wave inversion. The patient was planned for a temporary pacemaker (TPI) followed by a permanent pacemaker (PPI).

Under all aseptic precautions, TPI was introduced and placed, a rhythm was set at a rate of 80 bpm. No post-procedure complications.

The patient was subjected to a coronary angiogram in view of chronic diabetes. CAG showed normal coronaries. The patient was taken for PPI. No postprocedural events. Patient stabilized.


We have demonstrated here massive T wave inversion in the ECG of a patient who had syncope-a Stoke Adams syndrome – due to complete heart block.

The T waves shown here are deep, wide, and strikingly asymmetrical, and best seen in leads V2-V4.

A particular type of Giant T wave has been noted following Stokes Adams attack associated with complete heart block. This usually occurs in females; the T waves are deep, blunt, broad, often bizarre with prolonged QTC, and are usually maximum in leads V2 and V3.

A slow heart rate with prolongation of ventricular diastolic filling time and ventricular distention appears to be an important component in their causation.


Loss of consciousness appears to play an integral part in the production of these abnormal waves.

This suggests that the myocardial change may be cerebral in origin. It is probably triggered off by anoxia, acting locally on the heart muscle cells and producing a metabolic derangement that interferes with repolarization.

In this patient, ECG taken at the appropriate time made an immediate diagnosis possible.


Dr. Z. Mohamed Ghouse Khan

Head of Emergency