De Winter T wave

Introduction

De Winter T wave pattern initially reported in 2008 by De Winter et al. is an equivalent to anterior STEMI due to proximal LAD occlusion. It presents without obvious ST segment elevation. 

It is associated with high mortality within the first week and it seems to be a transient ECG phenomenon related to the first phases of myocardial ischemia. 

De Winter pattern is highly predictive for an acute LAD occlusion, therefore for anterior MI. 

It is recorded in approximately 2% of acute LAD occlusions. 

ECG manifestation 

  • upsloping ST depression at J-point > 1 mm in precordial leads
  • tall, prominent, symmetrical T waves in precordial leads
  • absence of ST elevation in the precordial leads 
  • slight ST segment elevation (0.5mm-1mm) in aVR

The ECG presentation of De Winter pattern may appear similar to hyperacute T waves as noted in hyperkalemia or early ischemia after total coronary artery occlusion; however, there is usually a complete resolution of hyperacute T waves within minutes, whereas De Winter pattern may last until primary percutaneous intervention or change into ST segment elevation.


Management

  • coronary angiography/PCI
  • UFH
  • ASA
  • P2Y12 inhibitors
  • nitrates

ECG 1 De Winter sign on ECG in a patient with proximal LAD occlusion


References

  1. de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA Interventional Cardiology Group of the Academic Medical Center. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008;359:2071–3
  2. Giovanni Barbati, Francesco Caprioglio. de Winter’s Pattern: An Unusual but Very Important Electrocardiographic Sign to Recognize. Volume 2, Issue 1, January 2020 https://doi.org/10.1016/j.cjco.2019.11.001
  3. Alahmad Y, Sardar S, Swehli H. De Winter T-wave Electrocardiogram Pattern Due to Thromboembolic Event: A Rare Phenomenon. Heart Views. 2020;21(1):40-44. doi:10.4103/HEARTVIEWS.HEARTVIEWS_90_19
  4. Wang H, Dai XC, Zhao YT, Cheng XH. Evolutionary de Winter pattern: from de Winter ECG to STEMI-A case report. BMC Cardiovasc Disord. 2020 Jul 6;20(1):324. doi: 10.1186/s12872-020-01611-0. PMID: 32631247; PMCID: PMC7339449.
  5. https://litfl.com/de-winter-t-wave-ecg-library/
  6. http://hqmeded-ecg.blogspot.com/2009/02/hyperacute-t-waves.html