STEMI Equivalents: De Winter’s T Waves

This is our second installment of STEMI Equivalents. Check out our first one on Wellen’s Syndrome.

So let’s get started!

De Winter’s T waves are seen in around 2% of LAD occlusions. Because it is not very common, many clinicians do not catch this and because of this, many patients do unfortunately experience loss of ejection fractions and even go into cardiac arrest. So what are De Winters T waves?

De Winters T Waves

De Winter's T Waves
https://pages.mrotte.com/de_winter/
De Winter ST/T-Waves - ECG Medical Training
https://www.ecgmedicaltraining.com/de-winter-stt-waves/

So what do we notice in these two 12 leads? There are some weird morphologies noted in the anterior leads with some ST depression and a peaked/hyperacute looking T wave. De Winters T waves are an Anterior wall STEMI Equivalent. So what are the criteria?

https://www.resus.com.au/de-winters-t-waves/
  1. Small elevation noted in aVR
  2. Upsloping ST segment depression in the precordial leads
  3. Loss of R wave progression
  4. Occasional slight QRS widening
  5. Positive peaked T waves in the precordial leads (yes these look similar to hyperkalemia but there are differences to get a better run down on hyperkalemia check out our YouTube video)

The De Winters T waves are sort of a precursor and a warning to a massive STEMI. Patients who have this sign, eventually go straight to tombstombing in the anterior leads very quickly which you can see an example of below:

Anterior Myocardial Infarction • LITFL • ECG Library Diagnosis
https://litfl.com/anterior-myocardial-infarction-ecg-library/

The higher the ST segment, the more myocardial cells have been affected which leads to a higher prognosis of mortality.

To further prove my point, I am going to show you the progression of De Winters into an Anterior STEMI that was missed which is showcased by Dr. Smiths ECG Blog (http://hqmeded-ecg.blogspot.com/). This is an amazing site for ECG training.

You can notice the upsloping ST segment especially in V3 and V4 with poor R wave progression. The T waves are symmetrical and peaked. This is a more subtle De Winters case.

Here you can see the patient is having a classic anterior STEMI with large hyperacute T waves in the precordial leads and pathological Q waves along with poor R wave progression.

This is to show you the progression from De Winters into an LAD occlusion. The patient was eventually stented per Dr. Smith’s ECG blog post. But what if the physician noticed De Winters T waves from the get-go? The patient’s anterior wall wouldn’t have been as infarcted and the patient would have had a higher quality of life.

We absolutely love Dr. Smiths ECG blog and highly recommend people to look through his cases.

For how to interpret a 12 lead ECG check out our post:

To catch yourself up on recognizing an occlusion MI (OMI) and noticing hyperacute T waves, check out this post:

This site is meant to be used for educational use only. We strive to push evidence based medicine with no bias to help you obtain all the important information. You should always follow your protocols that have been set in place.

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References

Barbati, G., & Caprioglio, F. (2019, November 11). De Winter’s Pattern: An Unusual but Very Important Electrocardiographic Sign to Recognize. Retrieved October 27, 2020, from https://www.sciencedirect.com/science/article/pii/S2589790X19300691

Bouthillet – 25 posts Tom Bouthillet (@tbouthillet) is Editor-in-Chief of ECGMedicalTraining.com (@ECGTraining) and Fire Captain/Paramedic in South Carolina where he is the Emergency Cardiac Care Program Manager an, T. (2016, May 24). De Winter ST/T-Waves. Retrieved October 27, 2020, from https://www.ecgmedicaltraining.com/de-winter-stt-waves/

Burns, E. (2019, September 24). De Winter T Wave • LITFL • ECG Library Diagnosis. Retrieved October 27, 2020, from https://litfl.com/de-winter-t-wave-ecg-library/

Engelen, D., Gorgels, A., Cheriex, E., Muinck, E., Ophuis, A., Dassen, W., . . . Wellens, H. (2000, June 12). Value of the electrocardiogram in localizing the occlusion site in the left anterior descending coronary artery in acute anterior myocardial infarction. Retrieved October 27, 2020, from https://www.sciencedirect.com/science/article/pii/S0735109799001977?via=ihub

Kas, P. (2019, June 27). De Winter’s T waves. Retrieved October 27, 2020, from https://www.resus.com.au/de-winters-t-waves/

Smith, S. (2012, December 12). Back pain radiating to the chest in a man in his 40’s. Retrieved October 27, 2020, from https://hqmeded-ecg.blogspot.com/2012/12/back-pain-radiating-to-chest-in-man-in.html

3 thoughts on “STEMI Equivalents: De Winter’s T Waves

  1. DrAman says:

    Lovely piece of knowledge great job extremely well elaborated my ecg skills improve dy by day and Drsmith is big help

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