The following ECG is from a 46-year-old man who has been brought by ambulance with chest pain and dyspnoea.

He looks pale and unwell; his vital signs are as follows: HR 100 BP 149/87 RR 24 Sats 94% RA T 36.

Interpretation:

Rate – 102 bpm

Rhythm – Sinus rhythm

Axis – Normal Axis

Intervals – Normal PR and QRS intervals

ST segments – The most striking abnormality is that of widespread ST segment depression.

Note is made of coved ST elevation of > 2mm in aVR with up-sloping STE in V1.

In almost all of the other leads there is up-sloping STD with hyper-acute T waves in the antero-septal leads.

This is a concerning ECG for myocardial ischaemia. The pattern of up-sloping ST segment depression at the J point in leads V1 to V6 was first described in 2008 by a Prof. Robbert Jan de Winter. They have since been described as de Winter T waves.

In patients with this pattern of ST depression there may be an absence of ST segment elevation. However, in his initial article in the New England Journal of Medicine, Prof de Winter described the incidence of 1-2mm of STE in aVR in the majority of their patients. This can be seen in our example.

This pattern is a recognised STEMI equivalent and highly sensitive for proximal LAD occlusion – as recognised in the Fourth Universal Definition of Myocardial Infarction. It is present is 2% of acute LAD occlusions and may lead to under treatment if not recognised.

Therefore, in our patient, appropriate management will consist of an ABC approach, loading with dual anti-platelet agents and enoxaparin/heparin, pain management with opiates and nitrates, and urgent reperfusion therapy with PCI or thrombolysis.

Further reading:

https://www.nejm.org/doi/full/10.1056/NEJMc0804737

https://pubmed.ncbi.nlm.nih.gov/19620137/

https://litfl.com/de-winter-t-wave-ecg-library/

Fourth Universal Definition of Myocardial Infarction 2018 – https://www.ahajournals.org/doi/10.1161/CIR.0000000000000617