Winter is Coming
aka ECG Exigency 016
A 54-year old man presents by private vehicle to the Emergency Department with chest discomfort he described as “heartburn.” The pain is substernal and non-radiating. He is also mildly diaphoretic.
There is no history of diabetes, hypertension, high cholesterol, or coronary artery disease. On arrival he is resting comfortably, with the following vitals: heart rate 56, blood pressure 125/82, respirations 18 per minute and unlaboured, oxygen saturation 100% on room air. His ECG is shown below:
Q1. Describe the ECG.
- Ectopic atrial rhythm: inverted P waves in II, III, aVF
- Rate 75 bpm
- Normal axis: +30 degrees, QRS complexes upright in leads I + II
- Normal intervals
- 1mm ST-segment elevation in aVR
- Upsloping ST-segment depression in V2-V6
- Tall, prominent, symmetric T waves throughout the precordial leads
Q2. What is the significance of these ECG findings?
These ST and T waves abnormalities are known as de Winter T-waves
This ECG finding:
- Is specific for left anterior descending artery (LAD) occlusion.
- Represents ~2% of LAD occlusions.
- May persist until the culprit artery is opened (making it a STEMI equivalent) or may evolve into an anterior STEMI.
Q3. How would you manage this patient?
This patient needs to be managed as a STEMI with analgesia, nitrates, oxygen, aspirin, heparin and (most importantly) emergent PCI or thrombolysis!
Q4. Can you guess what happened next?
The patient was admitted for emergent PCI.
- Angiography revealed a 100% mid-LAD occlusion, which was successfully stented.
- His troponin peaked at 197 ng/mL.
- The patient was eventually discharged with a normal ejection fraction.
Take home points
- The de Winter ECG pattern is a recently-described STEMI equivalent that emergency physicians and paramedics must be aware of.
- These patients typically have critical stenosis of the LAD requiring emergent PCI or thrombolysis.
- Lack of familiarity with these ECG findings may lead to reluctance to activate the cath lab and unacceptable delays in reperfusion.
- Remember that in many cases the de Winter pattern persisted until after the target artery was opened. Don’t wait for serial ECGs to evolve into a more easily recognisable STEMI pattern (which may never happen): activate the cath lab now!
CLINICAL CASES
ECG Exigency
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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excellent, Ed.
may i suggest a few more points?
1. reciprocal changes inferiorly, with ST set depression, and flipped T’s
2. hyper acute T’s in V1-4 (you mentioned) alone would be worrisome for acute OMI (occlusive MI).
3. mattu has said the an upright T in V1, esp if its higher than the T in V6 (unless its all old), is worrisome.
4. very poor R-wave progression V1-3.
thank you for this excellent example of de Winters.
tom