54 year old male with a history of CAD s/p cardiac stenting 3 years ago presented to ED complaining of substernal chest pressure since last night, radiating to bilateral shoulders. NO improvement in CP after sublingual Nitroglycerin. ECG is shown below.

Interventional Cardiology took the patient to cath lab. Heart catheterization showed 100% LAD occlusion. Initial Troponin came back when patient was already in a cath lab and it was 30.

Look at this ECG carefully.

There is no obvious ST elevation, except in aVR. Looking at the precordial leads, there are peculiar ST segment depressions with peaked T waves. These are De Winter T-waves:

De Winter T waves are presents in <2% of LAD occlusions and are considered an anterior wall STEMI equivalent.

Diagnostic criteria:
Tall symmetric T waves in precordial leads
No ST elevation in precordial leads
Upsloping ST segment depression >1mm at the J-point in the precordial leads
ST elevation in aVR (may be <1 mm)

A patient presenting with chest pain and de Winter T-waves should be treated with PCI or thrombolysis.

Courtesy of Virat Patel and Karima Sajadi
Keywords: STEMI equivalent, De Winter T waves

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