First reported by Dutch Professor of Cardiology, Robbert J. de Winter in 2008, the de Winter ECG pattern is an anterior STEMI equivalent that presents without obvious ST segment elevation. These patients are suffering occlusion myocardial infarction (OMI) and require immediate reperfusion therapy.
ECG Diagnostic Criteria
- Tall, prominent, symmetrical T waves in the precordial leads
- Upsloping ST segment depression > 1mm at the J point in the precordial leads
- Absence of ST elevation in the precordial leads
- Reciprocal ST segment elevation (0.5mm – 1mm) in aVR
- Typical STEMI morphology may precede or follow the De Winter pattern
Original reports of the de Winter pattern suggested that the ECG did not change or evolve until the culprit artery had been opened. Since then, cases have been reported where the de Winter pattern evolved from, or evolved to, a “classic” anterior STEMI.
Clinical Significance of de Winter T Waves
- The de Winter pattern is seen in ~2% of acute LAD occlusions and is often under-recognised 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
Background
1947 – The de Winter ECG pattern was first reported by William Dressler (1890-1969) in a study including “Twenty-seven instances of myocardial infarction were studied, in which the first electrocardiogram was taken as early as one and one-quarter hours, and not later than twelve hours, after the onset of symptoms.”
In five cases (18%), high T waves were not associated with abnormal elevation of S-T, nor with significant changes in QRS. Thus, they represented the leading diagnostic sign in the early stage of myocardial infarction.
Dressler, Roesler 1947
Fig. 3; case 4. Signs diagnostic of anteroseptal infarction. Dressler, Roesler 1947
A: 3 hours after the onset of the attack, shows high T waves in the chest leads associated with abnormal depression of S-T; especially Leads CR3-CR6.
B: 18 hours post symptom onset. Significant changes in QRS appeared when the high T waves had decreased in amplitude and become semi-inverted.
C: 3 days post onset; and D: 7 days post onset, show progressive inversion of the previously high T waves.
2008 – The de Winter ECG pattern was first reported in a case series by de Winter RJ, Verouden NJ, Wellens HJ et al. They observed this ECG pattern in 30 / 1532 patients with acute LAD occlusions (2% of cases)
2009 – Verounden and colleagues replicated this finding in a further case series. They found a de Winter ECG pattern in 35 / 1890 patients requiring PCI to the LAD (2% of cases). Patients with the de Winter ECG pattern were younger, more likely to be male and with a higher incidence of hypercholesterolaemia compared to patients with a classic STEMI pattern
In patients presenting with chest pain, ST-segment depression at the J-point with upsloping ST-segments and tall, symmetrical T-waves in the precordial leads of the 12-lead ECG signifies proximal LAD artery occlusion. It is important for cardiologists and emergency care physicians to recognise this distinct ECG pattern, so they can triage such patients for immediate reperfusion therapy
Verouden NJ 2009
The de Winter ECG pattern is now considered a “STEMI-equivalent” and an indication for immediate reperfusion therapy in many acute coronary syndrome guidelines
Example ECGs
Example 1
De Winter T waves
- Upsloping ST depression in the precordial leads (> 1mm at J point)
- Peaked anterior T waves (V2-6), with the ascending limb of the T wave commencing below the isoelectric baseline
- Subtle ST elevation in aVR > 0.5mm
There is also some high lateral involvement, with subtle ST elevation in aVL plus reciprocal change in III + aVF. This is consistent with LAD occlusion occurring proximal to the first diagonal branch.
Example 2
De Winter T waves
- Upsloping ST depression in the precordial leads (> 1mm at J point)
- Peaked anterior T waves (V2-6), with the ascending limb of the T wave commencing below the isoelectric baseline
- Subtle ST elevation in aVR > 0.5mm
Example 3
De Winter T waves
- Upsloping ST depression (> 1mm at J point) in the precordial leads V2-6, plus leads I and II
- Peaked anterior T waves, with the ascending limb of the T wave commencing below the isoelectric baseline
- ST elevation in aVR > 0.5mm
Thanks to Dr Steve Smith for contributing this De Winter’s T wave ECG
Example 4
De Winter T waves (morphing into Anterior STEMI)
This great ECG demonstrates de Winter’s T waves combined with features of anterior STEMI — the patient ultimately turned out to have an acute proximal LAD occlusion.
- Upsloping ST depression and peaked T waves (De Winter’s T waves) in V3-6.
- ST elevation in the septal (V1-2) and high lateral leads (I & aVL) with inferior reciprocal change, consistent with an LAD occlusion proximal to the first diagonal branch.
Thanks to Jennifer Davidson for contributing this ECG.
Example 5
Example 6
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