De Winter T Wave

Clinical Significance of De Winter T Waves

The de Winter ECG pattern is an anterior STEMI equivalent that presents without obvious ST segment elevation. First reported by first reported de Winter in 2008

  • Key diagnostic features include ST depression and peaked T waves in the precordial leads.
  • The de Winter pattern is seen in ~2% of acute LAD occlusions and is under-recognised by clinicians.
  • Unfamiliarity with this high-risk ECG pattern may lead to under-treatment (e.g. failure of cath lab activation), with attendant negative effects on morbidity and mortality.
ECG de Winter T-waves V3 strip

Background

  • The de Winter ECG pattern was first reported in a 2008 case series by de Winter RJ, Verouden NJ, Wellens HJ et al. They observed this ECG pattern in 30 / 1532 patients with acute LAD occlusions (2% of cases).
  • Verounden and colleagues replicated this finding in a 2009 case series. They found a de Winter ECG pattern in 35 / 1890 patients requiring PCI to the LAD (2% of cases). Patients with the de Winter ECG pattern were younger, more likely to be male and with a higher incidence of hypercholesterolaemia compared to patients with a classic STEMI pattern.
  • There is now growing evidence to suggest that the de Winter ECG pattern is highly predictive of acute LAD occlusion.
  • Some authors have proposed that the de Winter pattern should be considered a “STEMI equivalent”, and that patients with chest pain and this ECG pattern should receive emergent reperfusion therapy with PCI or thrombolysis.

In patients presenting with chest pain, ST-segment depression at the J-point with upsloping ST-segments and tall, symmetrical T-waves in the precordial leads of the 12-lead ECG signifies proximal LAD artery occlusion. It is important for cardiologists and emergency care physicians to recognise this distinct ECG pattern, so they can triage such patients for immediate reperfusion therapy.– Verouden NJ 2009

de Winter T-waves

Diagnostic Criteria

  • Tall, prominent, symmetric T waves in the precordial leads
  • Upsloping ST segment depression >1mm at the J-point in the precordial leads
  • Absence of ST elevation in the precordial leads
  • ST segment elevation (0.5mm-1mm) in aVR
  • “Normal” STEMI morphology may precede or follow the deWinter pattern

Original reports of the de Winter pattern suggested that the ECG did not change or evolve until the culprit artery had been opened. Since then, cases have been reported where the deWinter pattern evolved from, or evolved to a “classic” anterior STEMI.


Example ECG

Example 1
ECG De Winter T Waves 1

De Winter T waves

  • Upsloping ST depression in the precordial leads (> 1mm at J-point).
  • Peaked anterior T waves (V2-6), with the ascending limb of the T wave commencing below the isoelectric baseline.
  • Subtle ST elevation in aVR > 0.5mm.

There is also some high lateral involvement, with subtle ST elevation in aVL plus reciprocal change in III + aVF. This is consistent with LAD occlusion occurring proximal to the 1st diagonal.


Example 2
ECG De Winter T Waves 2

De Winter T waves

  • Upsloping ST depression in the precordial leads (> 1mm at J-point).
  • Peaked anterior T waves (V2-6), with the ascending limb of the T wave commencing below the isoelectric baseline.
  • Subtle ST elevation in aVR > 0.5mm.

Example 3
ECG De Winter T Waves 3

De Winter T waves

  • Upsloping ST depression (> 1mm at J-point) in the precordial leads V2-6, plus leads I & II.
  • Peaked anterior T waves, with the ascending limb of the T wave commencing below the isoelectric baseline.
  • ST elevation in aVR > 0.5mm.

Thanks to Dr Steve Smith for contributing this De Winter’s T wave ECG


Example 4
ECG De Winter T Waves 4

De Winter T waves (Morphing into Anterior STEMI)

This great ECG demonstrates de Winter’s T waves combined with features of anterior STEMI — the patient ultimately turned out to have an acute proximal LAD occlusion.

  • Upsloping ST depression and peaked T waves (De Winter’s T waves) in V3-6.
  • ST elevation in the septal (V1-2) and high lateral leads (I & aVL) with inferior reciprocal change, consistent with an LAD occlusion proximal to the 1st diagonal.

Thanks to Jennifer Davidson for contributing this ECG.


Example 5
ECG de Winter waves proximal LAD occlusion

Example 6
De Winter T waves ECG pre-arrest

Cases


References

  • Smith S. Back pain radiating to the chest in a man in his 40’s
  • Smith S. Spontaneous Reperfusion and Re-occlusion
  • de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008 Nov 6;359(19):2071-3. [PMID 18987380]
  • Verouden NJ, Koch KT, Peters RJ, Henriques JP, Baan J, van der Schaaf RJ, Vis MM, Tijssen JG, Piek JJ, Wellens HJ, Wilde AA, de Winter RJ. Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion. Heart. 2009 Oct;95(20):1701-6. [PMID 19620137]
  • Engelen DJ, Gorgels AP, Cheriex EC, De Muinck ED, Ophuis AJ, Dassen WR, Vainer J, van Ommen VG, Wellens HJ. Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction. J Am Coll Cardiol. 1999 Aug;34(2):389-95 [PMID 10440150]
  • Zimetbaum PJ , Josephson ME. Use of the electrocardiogram in acute myocardial infarction. N Engl J Med. 2003 Mar 6;348(10):933-40. [PMID 12621138]
  • Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med. 2003 Nov 27;349(22):2128-35. [PMID 14645641]
  • Li RA, Leppo M, Miki T, Seino S, Marbán E. Molecular basis of electrocardiographic ST-segment elevation. Circ Res. 2000 Nov 10;87(10):837-9. [PMID 11073877]

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Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

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