De Winter T Wave

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
ECG de Winter T-waves V3 strip
De Winter T Waves: Upsloping ST depression and peaked T waves in precordial leads

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
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 1947A: 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
de Winter T-waves

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
ECG De Winter T Waves 1

De Winter T waves

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

Example 3
ECG De Winter T Waves 3

De Winter T waves

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.

Thanks to Jennifer Davidson for contributing this ECG.

Example 5
ECG de Winter waves proximal LAD occlusion
Example 6
Cases
References
Advanced Reading

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Textbooks

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