Beyond Ischemia: A Curious Case of Electrocardiographic Abnormalities in COVID-19 Without Myocardial Injury

T-wave inversion (TWI) on electrocardiography (ECG) is a nonspecific finding that may reflect a wide range of cardiac and non-cardiac conditions. Since the emergence of COVID-19, there has been growing recognition of its diverse cardiovascular manifestations, including ECG abnormalities in the absence of traditional causes such as coronary artery disease. We present a case of significant TWI and QTc prolongation in a patient with COVID-19, underscoring the potential impact of the virus on cardiac electrophysiology and autonomic regulation. A 68-year-old woman with a history of paroxysmal atrial fibrillation presented with dizziness and hypotension. ECG revealed marked TWI and QTc prolongation, despite normal troponin levels. She tested positive for COVID-19, though her course did not require respiratory support. Further evaluation with echocardiography and coronary angiography excluded ischemic or structural heart disease, and alternative non-cardiac metabolic causes of TWI were also excluded. The findings were, therefore, attributed to autonomic dysfunction in the setting of COVID-19 infection. Her symptoms and ECG changes resolved over six months, consistent with a transient process. This case highlights the variable cardiac manifestations associated with COVID-19 and emphasizes the importance of recognizing TWI as a possible indicator of viral-induced cardiac involvement, even in the absence of conventional cardiovascular disease. It also reinforces the need for careful interpretation of ECG abnormalities in this population, given their potential prognostic significance. The transient course observed here suggests a reversible mechanism, possibly related to autonomic imbalance or direct viral effects on myocardial conduction. Further investigation is warranted to better delineate these mechanisms and inform targeted management strategies for patients with COVID-19-related cardiac involvement.