Friday, February 10, 2023

What is the ECG Diagnosis?

I came across this ECG while reading ECGs for Cardiologs in order to train the Cardiologs Deep Convolutional Neural Network.  I don't have any clinical information or any other associated ECGs on this case, but wanted to post it here because it is interesting and it is pathognomonic.

What is it?

This is a proximal LAD Occlusion.  

First, there are hyperacute T-waves in V2-V4.  These are preceded by ST depression and are de Winter's T-waves, though somewhat atypical.  There is also a hyperacute T-wave in aVL with subtle STE.  There is reciprocal ST depression in II, III, and aVF: it is more visually apparent than the STE in aVL but this is a common occurrence.  Inferior ST Depression does NOT mean there is inferior subendocardial ischemia; it is generally reciprocal to high lateral (aVL) subepicardial ischemia (OMI/STEMI)


MY Comment by KEN GRAUER, MD (2/10/2023):


There are certain patterns in ECG interpretation that experienced providers are able to immediately recognize. Among these patterns are de Winter T waves — which is the reason Dr. Smith selected the ECG in today's case. 
  • Because of the importance of this entity — we continue to periodically review it in cases we present (See the May 2, 2019 post — among many others).

DWinter T Waves:

In 2008 — Robert J. de Winter and colleagues (Drs. Verouden, Wellens, and Wilde) submitted a Letter to the Editor to the New England Journal of Medicine (N Engl J Med 359:2071-2073, 2008) — in which they described a “new ECG pattern” without ST elevation that signifies acute occlusion of the proximal LAD (Left Anterior Descending) coronary artery.

  • The authors recognized this pattern in 30 of 1532 (~2%) patients with acute anterior MI. Cardiac cath confirmed LAD occlusion in all cases — with ~50% of patients having a "wraparound" LAD. Left mainstem occlusion was not present.
  • This was the authors’ original description of the new ECG pattern: “Instead of the signature ST-segment elevation — the ST segment showed 1-3 mm of upsloping ST depression at the J point in leads V1-to-V6 — that continued into tall, positive symmetrical T waves”.
  • The QRS complex was usually not widened (or no more than minimally widened).
  • Most patients also manifested 1-2 mm of ST elevation in lead aVR.

 For illustrative purposes — I’ve adapted Figure-1 from the original manuscript by de Winter et al, published in this 2008 NEJM citation.
Figure-1: The de Winter T Wave Pattern, as first described by Robbert J. de Winter et al in N Engl J Med 359:2071-2073, 2008. ECGs for the 8 patients shown here were obtained between 26 and 141 minutes after the onset of symptoms. (See text).

In their original 2008 manuscript — de Winter et al went on to describe the following additional features:

  • “Although tall, symmetrical T waves have been recognized as a transient early feature that changes into overt ST elevation in the precordial leads — in this group of patients, this new pattern was static, persisting from time of the 1st ECG until the pre-cath ECG.”
  • Hyperkalemia was not a contributing factor to this ECG pattern (ie, Serum K+ levels on admission were normal for these patients).   


NOTE: Technically speaking — the de Winter T wave pattern as described in 2008 by de Winter et al differs from the finding of simple "hyperacute" anterior T waves — because ECG findings with a strict de Winter T wave pattern persist for an hour or more until the “culprit” LAD vessel has been reperfused. 

  • As I note above (and as illustrated in the example ECGs taken from the de Winter manuscript that are shown in Figure-1) — there should be involvement in all 6 chest leads with the strict de Winter pattern, with most leads showing several mm of upsloping J-point ST depression and giant T waves.

MY Observations regarding De Winter T Waves: Over the past decade — I have observed literally hundreds of cases in numerous international ECG-internet Forums of de Winter-like T waves in patients with new cardiac symptoms.

  • Many (most) of these cases do not fit strict definition of “de Winter T waves” — in that fewer than all 6 chest leads may be involved — J-point ST depression is often minimal (if present at all) in many of the chest leads — and, the number of leads that manifest giant T waves is limited.
  • ECG changes in many of the cases that I have observed are not “static” until reperfusion (as had been initially reported in 2008 by de Winter et al.). Neveretheless, cath follow-up has routinely confirmed LAD occlusion in almost all cases.

MY “Take”
 on this Phenomenon: 

I believe there is a spectrum of ECG findings, that in the setting of new-onset cardiac symptoms is predictive of acute LAD occlusion as the cause. I suspect that to a large extent — what is seen on ECG depends greatly on when during the process the ECG is obtained.
  • While many of these patients do not manifest “true" de Winter T waves” (because their ECG pattern does not remain static until reperfusion by coronary angioplasty) — for the practical purpose of promptly recognizing acute OMI — I do not feel ( = my opinion) it matters whether a “true” de Winter T wave pattern vs simple “hyperacute” T waves (that are de Winter-like) are present.


Regarding Today’s Case: 

For clarity — I've reproduced the ECG in today's case in Figure-2. Comparing the chest lead ST-T wave appearance in ECG #1 with the example tracings from the original de Winter manuscript shown in Figure-1 — ECG #1 manifests some atypical features:

  • Extremely tall T waves in Figure-2 are limited to 3 leads (ie, leads V2,V3,V4) — rather than many more leads, as shown in Figure-1.
  • The chest lead that shows the most prominent T wave in today's case ( = lead V2) — does not show any J-point ST depression. In fact — None of the chest leads in ECG #1 show true J-point depression. On the contrary, instead of J-point depression leading into a rapidly ascending ST segment — there is ST segment sagging (RED arrows in leads V3,V4,V5).

  • BOTTOM LINE: ECG #1 does not satisfy criteria for a “STEMI” — because there is not enough ST elevation. It does not quite meet the original 2008 description for de Winter T waves. That said, as per Dr. Smith — it should still be obvious in a patient with chest pain, that acute proximal LAD occlusion must be assumed until proven otherwise!

Figure-2: I've labeled the initial ECG in today's case. (To improve visualization — I've digitized the original ECG using PMcardio).

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