Below are several examples of hyperacute T waves.
Click here for more great examples of hyperacute T-waves.
Click here for cases of "inferior" hyperacute T-waves.
Click here for more great examples of hyperacute T-waves.
Click here for cases of "inferior" hyperacute T-waves.
Click here for 10 Cases of HATW in lead V2: Ten (10) Examples of Hyperacute T-waves in Lead V2 (a few in V3), due to acute LAD occlusion
Click here for 10 Cases of HATW in leads V4-V6: Ten cases of hyperacute T-waves in V4-V6
Case 1 (Hyperacute T waves with ST depression--LAD occlusion). These are de Winter's T-waves.
The following is a perfect example of Anterior MI with LAD occlusion but WITHOUT any ST elevation. This is seen commonly, but only recently reported on by de Winter, Verouden, Wilde, and Wellens' in a long letter to the New England Journal (NEJM 359(19):2071-2073; Nov. 6, 2008).
Hyperacute T-waves with a depressed ST takeoff: de Winter's T-waves of LAD Occlusion
Case 2 (Hyperacute T waves present AFTER ST elevation is resolving). Click here for an even better case of this phenomenon.
This is the EKG of a previously healthy 40 year old man with one hour of chest pain and profound weakness and sense of "doom". He has a history of HTN, smoking, and family history. Vital signs and exam were normal.
A prehospital EKG had been done and is shown below (but has very poor quality)
This shows much ST elevation in anterior leads and illustrates an underrecognized phenomenon: hyperacute T waves are not only present early after occlusion, as the STEMI is developing, but also after the ST segment elevates AND they are present early after reperfusion as the ST segments are falling. They may be the only remaining clue to a reperfused LAD occlusion.
Case 3 (Hyperacute T waves misdiagnosed as Hyperkalemia).
49 yo man with 1 week of stuttering chest burning and tightness for 1-2 hours. Today the discomfort is associated with multiple episodes of vomiting and it is unremittant. The following EKG was obtained and hyperkalemia was diagnosed. The patient was treated with Calcium, Insulin, D50, and bicarbonate, with no change in the ECG. A bedside ultrasound revealed a possible anterior wall motion abnormality. The K returned at 2.9 mEq/L. There was an LAD occlusion that was opened and stented.
These T waves are NOT typical for hyperK. They are "fat" and wide, with a blunt peak and poor R-wave progression (especially V3). The T-waves of hyperkalemia are peaked and tented. See below:
Many thanks for the easy availability of your EKG images. I'm taking my Recertification exam in EM and wanted to get a good feel for the difference between the peaked T in hyperkalemia and the image of hyperacute Ts in early AMI. Your examples are now in my lexicon.
ReplyDeleteIf I'm in an area where PCI is not available, should I initiate thrombolysis in a patient with a typical ACS type chest pain for 3 hours with hyperacute T? Or should I start thrombolysis when it converts to STEMI?
ReplyDeleteThis from India...
DeleteI did thrombolyse a patient with hyperacute t wave ..... It got reverted for a while...... Patient condition improved... But after 2 hour hyperacute t wave reappeared ..... Though patient didn't have any symptoms.... We wanted to send patient for PCI PAMI..... Unfortunately patient took discharge against medical advice.....
Hyperacute T-waves are considered an indication for thrombolysis. Of course you should be sure that is what is going on. If you are not, wait a bit and get another EKG. The earlier lytics are given, the better they work (fresh clot is busted better than less fresh clot). OK?
ReplyDeleteSteve Smith
Do you have a reference for hyper acute t's being an indication for lyrics? Thx in advance.
DeleteThe 1996 or 2004 (can't remember which) ACC MI guidelines mention it as a consideration. There are no clinical trials of it. There is evidence that hyperacute T-waves are a sign of 1. much myocardium at risk and 2. myocardium that is viable and so can be saved.
DeleteCase 3:
ReplyDeleteSir, in V2 and V4 T wave - fat and wide but in V3 it looks like HyperK Twave - tall and tented compare to T wave in V2 and V4
To me it does not look tented, "as if held up by a string". But if you think it is, just measure a potassium!
DeleteSteve Smith
Case 1 and Case 2, ST depression in lead II, what does it signify? Is it reciprocal depression to LAD occlusion?
ReplyDeletereciprocal to high lateral STEMI due to LAD occlusion proximal to the first diagonal which supplies the high lateral wall.
DeleteI'm working in a centre where PCI is not readily available.
ReplyDeleteCan I give lytics to moment I see deWinter T waves in a patient with concerning chest pain?
Yes, it even says so in 2004 STEMI guidelines, the last time it was mentioned:
ReplyDeleteBecause the benefit of fibrinolytic therapy is directly related
to the time from symptom onset, treatment benefit is maximized
by the earliest possible application of therapy. The
constellation of clinical features that must be present
(although not necessarily at the same time) to serve as an
indication for fibrinolysis includes symptoms of myocardial
ischemia and ST elevation greater than 0.1 mV, in 2 contiguous
leads, or new or presumably new LBBB on the presenting
ECG (156,315). In the very early phase of STEMI, giant
hyperacute T waves may precede ST elevation (316)
Sir., How we localize site of LAD OCCLUSION., JUST BY SEEING ECG..
ReplyDeleteIf there is ST elevation in aVL, with reciprocal ST depression in III, then the lateral wall is being affected and this is due to the first diagonal branch off the LAD. Only an occlusion proximal to this will result in these ECG findings. Of course there are exceptions, but this is the rule.
Deletesir, how can we differentiate between a hyperacute T wave and ST elevation on ECG? kindly help me .i am a beginner..thanks in advance :)
ReplyDeleteThey are different. ST Elevation due to ischemia may be present with or without a hyperacute T-wave. A hyperacute T-wave may be present with or without ST elevation, or with ST depression (in which case it is called a "de Winter" T-wave. The prehospital ECG on this post has massive ST elevation with hyperacute T-waves.
Delete