Friday, January 31, 2025

Another MUST know ECG, and why its notoriety annoys Dr. Smith

Written by Magnus Nossen

The ECG below was obtained from 50-something male with a history of hypertension and tobacco use. The patient contacted the ambulance service after he experienced sudden onset chest pain and diaphoresis that had started 20 minutes prior. The ECG below ECG was recorded on the scene.


What is the cause of the ECG changes here? How will you manage this patient?


ECG #1


The ECG shows sinus rhythm with a narrow QRS complex. The frontal plane axis is about 0 degrees. Heart rate is 85 beats per minute. There are significant and widespread ST-segment and T wave changes. The ST-segment in lead V1 has upward convexity. Throughout the precordium (V2-V6) there is ST depression followed by bulky, hyperacute T waves. 

  • This ECG pattern was described by de Winter et. al in 2008, and is eponymously named after the main author. The de Winter ECG pattern (sometimes referred to as de Winter's T-wave pattern) consists of an ST-segment upsloping depression at the J point of 1 to 3 mm in leads V1 to V6, associated with tall, bulky or "hyperacute" T waves. 

The de Winter electrocardiogram pattern is an infrequent presentation, reported to occur in 2% to 3.4% of patients with anterior myocardial infarction (1). Below I have marked the J-point on the limb leads and the precordial leads showing the upsloping ST depression in leads V2-V6. There is a de Winter T- wave pattern also in lead I.



This ECG is diagnostic of a proximal LAD occlusion. This ECG pattern is my favorite example of how the STEMI criteria are fundamentally flawed. I was handed this ECG while caring for another OMI patient, and I immediately recognized this ECG pattern and activated the cath lab. If you have seen this pattern once — the diagnosis is obvious to you. The ECG-to-balloon time was short, only 35minutes. At cath there was a 100% proximal LAD occlusion, which was opened and stented.

  • This patient received optimal care. Troponin T peaked at 9378 ng/L. Echocardiography showed septal and apical hypokinesis, with a left ventricular ejection fraction of 35-40%. 
  • The hypokinesis was transient. Echocardiography 3 months following the infarct showed a normal ejection fraction of 55% without apparent hypokinesis! 
  • Due to the rapid treatment — much myocardium was saved, and the initial hypokinesis was due to myocardial stunning (see below). Peak troponin may be very high following rapid reperfusion. 

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Smith: This is a classic case and well managed, as it should be.  However, I get annoyed by the attention devoted to de Winter's T-waves because they are a TINY minority of subtle hyperacute T-waves that result from LAD Occlusion (LAD OMI).  They are the most recognizable of all the hyperacute T-waves because of the depressed ST takeoff.  This means that the less recognizable HATW are not recognized and so many patients get ignored!  Moreover, de Winter stated that the morphology was "persisent."  First, de Winter T-waves are NOT always persistent (in fact, frequently are not), but, more importantly, the same can be said for standard hyperacute T-waves: they very frequently do not evolve to ST Elevation.  We have a series of 20 TIMI-0 LAD Occlusions that do meet STEMI criteria.  17 have HATW.  None evolved to ST Elevation.  Under Review.

See all the other manifestations of HATW in LAD Occlusion: Ten (10) Examples of Hyperacute T-waves in Lead V2 (a few in V3), due to acute LAD occlusion


In addition, these hyperacute T-waves with a depressed ST takeoff were first described by Soo in 1995, but he gets little credit for that.  De Winter did not reference Soo.  I have referenced Soo 3 times.

Soo CS. Tall precordial T waves with depressed ST take-off: an early sign of acute myocardial infarction? Singapore Med J 1995;36(2):236–7.


 CS Soo, Lecturer and Cardiologist, Department of Medicine, Universiti Malaya, Malaysia
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Myocardial stunning is a state of cardiac dysfunction that can occurs in a portion of myocardium without necrosis after a brief interruption in perfusion. This typically occurs in the setting of a rapidly reperfused coronary artery following a myocardial infarction. In this situation, even after the ischemia is relieved and myocardial blood flow is restored — myocardial contractile function remains impaired for a variable period of time (usually days to a few weeks).


Image reproduced from Kloner, R.A. (2020) 


If you are a regular reader of this blog — this diagnosis will be easy for you, and you will manage this type of patient correctly with immediate revascularization. Unfortunately, for providers not familiar with this type of LAD OMI presentation — the diagnosis will likely be delayed, as will appropriate treatment.

Learning to recognize ECG findings consistent with OMI takes time and practice. Artificial intelligence can assist providers in detecting patients in need of emergent revascularization. The Queen of Hearts was not used in the management of today's patient. Had the AI model been used it would have identified the ECG as OMI with high confidence. Below you can see the QoH interpretation of the initial ECG in today’s case. 



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Two Additional Examples: ECG interpretation is pattern recognition — and pattern recognition takes practice both for humans and AI models. Below I have added ECGs from two other patients. Both cases below show a textbook de Winter ECG pattern. Originally recorded with a paper speed 50mm/sec ECGs — below these ECGs are compressed by 50% on the X-axis to "look" like they where recorded at 25mm/sec.



The above ECG is from man in his 80s with crushing chest pain. This patient suffered V-fib arrest soon after this ECG was recorded. Sadly, he could not be resuscitated. This ECG and patient outcome is a reminder of why it is so important to recognize this ECG pattern. 
  • Below is the Queen of heart explainability chart. The overall interpretation was OMI with high confidence.




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This 2nd Example shows the ECG from a 50-year old male with sudden onset typical chest pain. This is another example of the de Winter ECG pattern. At cath there was a subtotally thrombotic occlusion of a proximal LAD with TIMI 2 flow. Peak troponin T 5933 ng/L.



Again I have added the QoH explainability feature below. Overall interpretation was OMI high confidence. 



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Discussion: The de Winter ECG pattern is seen in about two percent of patients with LAD OMI. The pattern is mostly described with LAD OMI, but has been reported in other coronary distributions as well. This ECG pattern is seen in the acute phase of OMI and it these patients need to be taken immediately to the cath lab or, if primary PCI is not available they should be given thrombolytic therapy as a conventional STEMI. 

It was previously thought that the de Winter ECG pattern represents ECG changes when there is a minimal trickle of blood reaching the downstream myocardium. However, many patients with de Winter ECG pattern have TIMI 0 at angiography and the ECG pattern does not necessarily progress to STEMI.

See this page for more ECG cases involving de Winters pattern


Learning points:

  • The de Winter ECG pattern may remain unchanged never developing to STEMI. 
  • Time is myocardium and prompt revascularization improves patient outcomes.
  • Transient ischemia may lead to "stunning". Stunned myocardium will regain its function after a period of days to weeks.


References: 


Kloner, R. A. (2020). Stunned and hibernating myocardium: Where are we nearly 4 decades later?
Journal of the American Heart Association

Vilela, E. M., & Braga, J. P. (2024, January 31)The de Winter ECG Pattern. StatPearls - NCBI Bookshelf

De Winter, R. J., Verouden, N. J. W., Wellens, H. J. J., & Wilde, A. a. M. (2008). A new ECG sign of proximal LAD occlusion. New England Journal of Medicine.






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MY Comment, by KEN GRAUER, MD (1/26/2025):
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"Some patients read the textbook. Others don't". I offer this quote as my reflection on today's case. The 50-something year old man presented by Dr. Nossen certainly "read the textbook" regarding deWinter T waves in the initial ECG from today's case.

From the original description by deWinter et al (N Engl J Med 359:2071-2073, 2008) — There is 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 ~2% of patients with acute anterior MI (iein 30/1532 patients studied). 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


In their original 2008 manuscript — deWinter 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 deWinter T wave pattern as described in 2008 by deWinter et al differs from the finding of simple "hyperacute" anterior T waves — because ECG findings with a strict deWinter T wave pattern persist for an hour or more until the "culprit" LAD vessel has been reperfused.

  • As suggested from the 8 example ECGs taken from the deWinter manuscript (labeled A-thru-H, as shown in Figure-1) — there should be involvement in all 6 chest leads with the strict deWinter pattern, with most leads showing several mm of upsloping J-point ST depression and giant T waves.


Figure-1: Comparison of ECG findings in today's case (LEFT panel— with the deWinter T Wave Pattern, as first described by Robbert J. de Winter et al (N Engl J Med 359:2071-2073, 2008). ECGs for the 8 patients shown here from the original deWinter manuscript (labeled A-thru-) — were obtained between 26 and 141 minutes after the onset of symptoms.
=  =  =  =  =
NOTE: I have corrected in Figure-1 for an error that I believed was made by the authors in their original manuscript = Leads I and aVL were switched in Patient C in the original manuscript from what I show above. That original mounting of those 2 leads would make for an impossible frontal plane axis and unlikely ST-T wave picture. I believe what shows above in my Figure-1 is now correct).


Today's Patient "Read" the Textbook ... 
  • The initial ECG from today's patient clearly manifests the "Can't Miss!" typical deWinter T wave picture of marked, upsloping J-point ST depression — that continues into tall, positive symmetric T waves (seen here in 5/6 chest leads — with coved ST elevation in the remaining chest lead V1)
  • And, as if to say, "Don't dare delay my PCI!— there is also the "Can't Miss" picture of marked reciprocal ST depression in the inferior leads.

Is Inferior Lead ST Depression a Part of deWinter T Waves?
For as many cases as I have seen of this entity — I had to go back and look at the representative figure from the original manuscript to answer this question.
  • The ANSWER: As shown in Figure-1 — 6/8 of the representative ECGs from the original manuscript manifest inferior lead reciprocal ST depression in association with the deWinter T wave pattern in the chest leads.
  • The 2 representative ECGs that did not manifest reciprocal ST depression are from Patient B and Patient E. On the contrary — T waves in the ECGs from these 2 patients were prominently upright (perhaps with the slightest amount of ST depression in a couple of leads).
  • Bottom Line: While common to see inferior lead reciprocal ST depression with deWinter T waves — this is not an invariable finding.

Additional Observations from Figure-1:
  • The original manuscript notes that most patients in their study of deWinter T waves had ST elevation in lead aVR. This is seen in all 8 representative ECGs in Figure-1.
  • Finally — I found the variable ST-T wave picture in lead aVL highly interesting. One of my "Go To" leads when assessing for the likelihood of proximal LAD occlusion — is to look for ST elevation in lead aVL. Yet among the 8 representative ECGs in Figure-1 — the ST-T wave picture in lead aVL ranged from hyperacute ST elevation (in and C) — to a flat ST-T wave (in E) — to T wave inversion (in B and H).
  • Bottom Line: Even among these 8 "representative" tracings (from the 30 patients identified as manifesting deWinter T waves) — there is variability in the ECG picture of this entity.

New Observations regarding deWinter T Waves:
The "good news" — deWinter T waves are now accepted as a "STEMI Equivalent", even when there is no ST elevation (Ricci, Smith, et al — Ann Emerg Med, 2025 in Press). Emergency angiography is needed and indicated for this ECG pattern.
  • This Ricci, Smith et al manuscript add that deWinter T waves, "are in fact just a small but more easily recognized subset of hyperacute T waves" — and that most such patients with hyperacute T waves do not manifest the originally described deWinter T wave feature of a depressed ST segment takeoff.
  • Finally, Ricci, Smith et al acknowledge that while deWinter T waves were initially described as indication of acute coronary occlusion in the LAD distribution — that the deWinter T wave pattern may occur in any coronary distribution!

  • Grauer Note: Having now observed literally hundreds of cases in numerous international ECG-internet Forums of deWinter-like T waves in patients with new cardiac symptoms — many (if not most) of these cases do not fit the strict original definition of "deWinter T waves" — in that fewer than all 6 chest leads are often 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.
  • In addition — ECG changes in many of the cases I have observed are not “static” until reperfusion (as had been initially reported in 2008 by deWinter et al.). Neveretheless, cath follow-up has routinely confirmed LAD occlusion in almost all cases.
  • My Impression: In large part, the ECG findings seen depend greatly on when during the ongoing process of acute coronary occlusion the ECG is taken. 
  • Finally — hyperacute T waves with similar clinical implications as strictly defined deWinter T waves — appear to be a much more frequent occurence among patients with acute anterior OMI, than the 2% incidence initially cited by the deWinter group authors in their original manuscript.

  • Sobering Closing Note: Although the word is spreading that the deWinter T wave pattern is a STEMI-equivalent that merits prompt cath with PCI — all-too-many interventionists still deny (and delay) this initial treatment "because STEMI-criteria are not met". This needs to change. 






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