De Winter ST/T-Waves


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



Figure 1. De Winter ST/T-wave complexes showing J-point depression and upright, symmetrical T-waves (see Example 1 below). The patient was suffering LAD occlusion.

Example 1


Example 2


Example 3


De Winter ST/T-waves transitioning to ST-segment elevation (1 of 3)


De Winter ST/T-waves transitioning to ST-segment elevation (2 of 3)


De Winter ST/T-waves transitioning to ST-segment elevation (3 of 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 ( 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

de winter 6 wm

Example 7

de winter 7 wm

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

de winter 8 wm

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)


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.


About author

Tom Bouthillet
Tom Bouthillet - 25 posts

Tom Bouthillet (@tbouthillet) is Editor-in-Chief of (@ECGTraining) and Fire Captain/Paramedic in South Carolina where he is the Emergency Cardiac Care Program Manager and the STEMI and CARES Site Coordinator of his fire department.

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