aka ECG Exigency 015
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’s 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!
Learn More About De Winter’s T Waves
- Read the de Winter page from the LITFL ECG library for more detailed information on this topic, including more fantastic ECG examples, references from the literature and links to high-quality FOAMed resources!