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Instructors' Collection ECG: Hyperacute T Waves: de Winter T Waves

The Patient

This ECG is from a 57-year-old man complaining of sub-sternal chest pain for 30 minutes.  EMS found him pale, diaphoretic, and anxious.  We don't have other clinical information or past medical history.  


The rhythm is normal sinus rhythm at 98 bpm.   The QRS is narrow, and the PR and QTc intervals are within normal limits. In precordial leads V2 through V4, ST segments begin at a J point that is below the baseline by one small block (the computer reads all precordial leads as having a small J point depression).  From those depressed J points, there are upsloping ST segments leading into hyperacute T waves.   

This is called de Winter T wave pattern, and it is a sign of critical proximal occlusion of the left anterior descending coronary artery.  Dr. Robbert de Winter, et al, described this pattern in a letter to the editor of the New England Journal of Medicine in 2008.  Since then, it has been estimated to occur in about  2%-3.4% of acute occlusive myocardial infarctions. It has been seen in occlusions of other major arteries, but by far most cases are seen in LAD occlusion.  This should not be considered to be an "impending M.I.", but rather a STEMI equivalent, warranting emergent treatment in a cath lab. 

In this ECG, we see a curving upward of the ST segment in aVR, with very slight STE noted by the computer.  ST elevation in aVR is a common finding with proximal LAD occlusion.  There is also subtle ST elevation in I and aVL with reciprocal ST depression in II, III, and aVF without hyperacute T waves, common when the occlusion is so proximal it affects the obtuse marginal branch of the circumflex or first diagonal branch of the LAD.

The J point changes of the de Winter pattern are seen with hyperacute T waves.  T waves are considered hyperacute if they are larger than normal for the lead they are seen in.  When we say, "large", it refers more to the width of the base of the T waves, and the space contained within the T wave, although they can be quite tall sometimes.  A tall, but narrow and pointed T wave would be more indicative of hyperkalemia than of de Winter pattern. 

Follow up

Unfortunately, we don't have follow up information on this patient, other than he arrived at the Emergency Department alive and was scheduled for the cath lab. 

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An Interesting Holter Strip

Here you can see a long rhythm strip from a Holter ECG, written at 25 mm/s. On the left, a sinus bradyarrhythmia can be seen first, followed by an atrial tachycardia. After a few beats this changes back into a sinus bradyarrhythmia. Then follows a short VT over 3 beats, after 1 sinus node beat then a ventricular couplet. Sinus bradyarrhythmia again at the end.

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Atrial Fibrillation With Rate-related Left Bundle Branch Block

For a better overview, the leads aVL and V2-V4 are not shown in this ECG. The basic rhythm is atrial fibrillation (no P waves or flutter waves visible, but fibrillation waves). When the conduction rate drops, the QRS complexes are narrow. Faster conduction results in wide QRS complexes with LBBB morphology. This is an example of phase 3 (acceleration dependant) LBBB.

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New Book From Dr. Jerry Jones


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ECG Glossary from Dr. Ken Grauer

Are you looking for a comprehensive ECG glossary that goes beyond simply defining words? Dr. Ken Grauer, who is the ECG Guru's Consulting Expert, has a Glossary available on his website that explains the terms.  Instructors and students alike will benefit from having this glossary readily available.  The glossary is exerpted from his e-Publication, "A 1st Book On ECGs - 2014", available on Amazon.

Coronary Arteries Anterior View Labeled

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Anterior view of coronary arteries

This is an original illustration by Dawn Altman.  It is free for your use in an educational setting.  For other uses, please contact Dawn at [email protected].


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ECG HISTORY:     ECG was first put into clinical use in the early 1900s.  In 1909, it helped diagnose an arrhythmia.  A year later, indications of a heart attack were noted.



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