An Interesting ECG Case
58-Year-Old Male with De Winter T Waves
A 58-year-old male presents with crushing chest pain radiating to his jaw, beginning two hours prior. He called 911, and EMS arrived 10 minutes later.
EMS performed an ECG en route to the hospital.
The doctor on call for CODE STEMI reviewed the ECG and directed the patient directly to the cath lab. Why?
Despite the absence of classical ST elevation, the ECG is typical of “De Winter T Waves” (N Engl J Med. 2008 Nov 6;359(19):2071-3). This raises the suspicion of a proximal left anterior descending (LAD) artery occlusion.
ECG demonstrates:
Probable ectopic atrial rhythm
Peaked “hyperacute” anterior T waves (V2-6), with the ascending limb of the T wave commencing below the isoelectric baseline
No clear ST elevation in the anterior leads
Subtle ST elevation aVR
Course:
Coronary angiography confirmed 100% occlusion of the proximal LAD. The artery was successfully reopened with primary PCI, and a drug-eluting stent (DES) was placed.
Teaching points:
The De Winter T wave pattern is an important STEMI-equivalent finding. It suggests proximal LAD occlusion, which requires immediate recognition and activation of the Code STEMI protocol.
De Winter T waves are characterized by upsloping ST depression with peaked T waves in precordial leads and may be missed if not specifically looked for.
Rapid recognition and treatment are essential to prevent extensive myocardial damage.
