De Winter ST/T-Waves
Objective
Understand and identify de Winter ST/T-waves as a STEMI equivalent
De Winter ST/T-Waves
- ECG abnormality described by de Winter et al. in 1998
- Characterized by 1-3 mm of ST-depression with upright, symmetrical T-waves
- Changes are dynamic as you would expect with ACS (see Example 3 below)
- Suspicious for proximal occlusion of the LAD
- Represents approximately 2% of LAD occlusions
- Recognized as a STEMI equivalent by Rokos et al. in 2010
Graphic
Example 1
Example 2
Example 3
Thanks to my good friend David Hildebrandt (@HildebrandtDave) for sharing this interesting series of ECGs.
Example 4
This tracing was first shared with me as an example of hyperacute T-waves by Darlene Petersen (ekgtools.com) at the old EKG Club on Yahoo! years before anyone had heard of de Winter T-waves!
Example 5
This was a patient with chest pain, bifascicular block, and LAD occlusion. Note the de Winter-like appearance of the ST/T-waves in leads V2-V5. If memory serves Amal Mattu, M.D. used this in a “case of the week” several years ago but I can’t seem to locate the video. (Update: Found it!)
Example 6
Example 7
This was reported to be a circumflex occlusion by the cardiac cath lab manager. I have a feeling she made an error and this was actually LAD occlusion (especially considering the tiny Q-waves in leads V3 and V4) but it’s possible this was an acute posterior STEMI. Sure looks like de Winter ST/T-waves to me!
Example 8
Low voltage de Winter ST/T-waves in a patient with angiographically confirmed LAD occlusion.
Example 9
Further Reading
- Click here for several cases studies by Stephen Smith, M.D. (@SmithECGBlog)
- Click here for more examples from Life in the Fast Lane
- Click here and see Figure 1 in the original article by de Winter in the New Engl J Med
- Click here to watch a video about de Winter ST/T-waves by Amal Mattu, M.D. (@amalmattu)
References
de Winter R, Verouden N, Wellens H, Wilde A. A New ECG Sign of Proximal LAD Occlusion. New England Journal of Medicine. 2008;359(19):2071-2073. doi:10.1056/nejmc0804737.
Rokos I, French W, Mattu A et al. Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction. American Heart Journal. 2010;160(6):995-1003.e8. doi:10.1016/j.ahj.2010.08.011.
Verouden N, Koch K, Peters R et al. Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion. Heart. 2009;95(20):1701-1706. doi:10.1136/hrt.2009.174557.