De Winter pattern (electrocardiogram)

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An electrocardiographic finding suggestive of impending myocardial infarction, the de Winter's pattern (or "de Winter's T-waves") describes an abnormality thought to be indicative of acute occlusion of the proximal left anterior descending coronary artery (LAD) . Timely recognition of this pattern is crucial; earlier percutaneous coronary intervention (PCI) reduces morbidity and mortality in myocardial infarction.

Epidemiology

This atypical presentation of acute LAD occlusion (and/or anterior myocardial infarction) more commonly presents in the following groups:

  • younger patients
    • males > females
  • history of hypercholesterolemia

Clinical presentation

ECG

While originally described as an early, static, and unique finding, the de Winter T wave pattern has subsequently been demonstrated to precede classic ST segment elevation, as well as occur in other coronary lesions, including left main coronary artery occlusion. The described pattern appears as follows :

  • upsloping ST segment depression at the J point
    • some or all of precordial leads V1-6
  • tall, symmetric precordial T waves
    • peaked appearance
    • some patients will have poor R wave progression (PRWP)
  • elevation of the ST segment in lead aVR
    • usually > 0.5 mm
  • normal to slightly prolonged QRS duration

Differential diagnosis

  • subacute pLAD occlusion
    • may produce the biphasic T waves of Wellen's syndrome
    • de Winter's T waves are thought to imply an occlusion of higher acuity
  • hyperkalemia
    • tall, peaked symmetric T waves
    • often associated with other findings such as;
      • bradycardia
      • prolonged QRS duration
      • conduction blocks
  • left main coronary artery occlusion
    • depression of ST segments typically diffuse