Saturday, January 19, 2019

Anterior STEMI Evolves to de Winter's T-waves


A middle-aged man called EMS for chest pain.

This prehospital ECG was recorded:
Obvious Anterior STEMI due to proximal LAD occlusion (with STE in aVL and reciprocal STD in inferior leads).

On arrival to the ED, this ECG was recorded 10 minutes later:
Almost all STE is gone, but the hyperacute T-waves remain


While waiting for the cath team, this was recorded 30 minutes after 2nd ECG:
Now there are classic de Winter's T-waves.
This shows the dynamic nature of coronary thrombus.  Presumably, the thrombus had autolysis to a very small degree, allowing a trickle of blood flow through the LAD, enough to eliminate the ST elevation.

The patient was found to have a 100% proximal LAD occlusion.

By the time of the angiogram, which is never at the same the time as the ECG, there was not even a trickle of blood.

See this related post, with discussion of de Winter's T-waves:

Is the LAD really completely occluded when there are de Winter's waves?

2 comments:

  1. Exceptional (STE, only T-wave, de Winter)
    Between 2.ECG (hyperacute T-wave AFTER STE) and 3.ECG (de Winter)
    it's possible to establish which of the two is "more occluded"
    (or "more reperfused") ?
    Thanks - Al

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    Replies
    1. I believe that it is more open with the deWinter's, but this is because it is all in transition. A completely occluded artery can have hyperacute T-waves without any ST shift (STD or STE) because the ST has not YET shifted. In this case, I think the artery opened just a trickle and the ST was shifting from STE to STD but had not YET become depressed.

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