ECG Exigency 015
- 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?
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?
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!