ecg

Training Blog – De Winter’s T Waves

By Dr Peter Kas at www.resus.com.au

De Winters T Waves were first described by the author in an article to the editor of the New England Journal of Medicine (1) in 2008. They are considered an ST-elevation myocardial infarction (STEMI) equivalent and a myocardial infarction can be missed in a patient as they do not have the classic ST-elevation appearance.

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Using ECG’s from a large database the authors described a new ECG pattern without ST elevation that indicated proximal left anterior descending (LAD) coronary artery occlusion.

The pattern was seen in the precordial leads and comprised:
– ST segment depression at the J point of precordial leads of at least 1mm
– Upsloping ST segments
– Peaked positive symmetrical T waves
– VR also showed small ST Elevation (1-2mm)

This pattern was recognised in 2% of patients (30/1532) with anterior myocardial infarction.

It was described as a static pattern, rather than evolving with changes to the ST segments. Since then other studies have shown evolution to classic STEMI does occur. This is now considered to be an anterior STEMI Equivalent.

In 2009 Verovden el al (2) duplicated these findings in patients with anterior wall myocardial infarction. The distinct ECG pattern was identified in approximately 2% of patients with LAD stenosis, in that study also. These patients were more likely to be younger and male and tended to have hypercholesterolaemia.

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References
1. De Winter Rd et al A new sign of proximal lad occlusion, NEJM 2008:359: 2071-2073 Nov 6
2. Verovden NJ Et al Persistent precordial “hyperacute” T waves signify proximal left anterior descending artery occlusion. Heart, 2009 Oct; 95(2): 1701-6