T-wave inversions are commonly found in many conditions other than ACS. Many pulmonary conditions, elevated intracranial pressure, LVH, bundle branch block, and young age are associated with T-wave inversions.
T-wave inversions are especially notable in patients with pulmonary embolism, and one study identified a key difference in T-wave inversion patterns in PE vs. ACS: T-wave inversions in leads III and V1 simultaneously were far more likely to be assocaite with PE, whereas the presence of T-wave inversions in I and aVL were almost always ACS.
A key takeaway point is to maintain a broad differential even in the presence of T-wave inversions...it's not necessarily just ACS!
[ref: Kosuge M, et al. Electrocardiographic differentiation between acute PE and ACS on the basis of negatie T waves. Am J Cardiol 2007;99:817-821.]
