aka ECG Exigency 016
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:
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
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.
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!
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!
- Hampton, JR. The ECG In Practice, 6e
- Mattu A, Brady W. ECG’s for the Emergency Physician 1
- Mattu A, Brady W. ECGs for the Emergency Physician 2
- Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric, 6e
- Wagner, GS. Marriott’s Practical Electrocardiography 12e
LITFL Further Reading