56 y/o male with 2 hours history of chest pain. He has a past medical history of HTN and smoking. An ECG was performed.

Rate:

• 72 bpm

Rhythm:

• Regular
• Sinus rhythm

Axis:

• Normal

Intervals:

• PR – Normal (180-200ms)
• QRS – Normal (80ms)
• QT – 360ms

Segments:

• ST Depression leads I, II, aVL, V2-6
• ST-Elevation lead aVR (~1mm)

Additional:

• Markedly prominent T waves leads I, V2-6

Interpretation:

De Winter’s T Wave Pattern

Suggests an acute LAD lesion requiring emergent reperfusion.

• DDx Demand ischemia/perfusion mismatch

• De Winter’s Pattern
  • Hyperacute T waves with associated ST depression in leads V2-6
  • Possible ST-elevation aVR

  • Clinical Significance of de Winter T Waves

    • The de Winter pattern is seen in ~2% of acute LAD occlusions and is often under-recognized by clinicians
    • Key diagnostic features include ST depression and peaked T waves in the precordial leads
    • Unfamiliarity with this high-risk ECG pattern may lead to delays in appropriate treatment (e.g. failure of cath lab activation), with attendant negative effects on morbidity and mortality

    “Normal” STEMI morphology may precede or follow the De Winter pattern

Management:

This patient is definitely has a very concerning history along with ECG findings (De Winter pattern). The following management should be considered.

1. Serial ECGs to ensure he does not develop any dynamic ECG changes.
2. Urgent discussion with the cardiologist for consideration of emergency angiogram/PCI.
3. Treatment as ACS if no contraindications for antiplatelet and anticoagulation.
4. Serial troponins.

Closure: 

• The patient was taken for emergency PCI which showed:
  LAD – 100% Occlusion – 2 x stents inserted
• RAC – 30% proximal stenosis

Reference/Further Readings:

De Winter T Wave