A middle-aged man presented to the ED with chest pain for the past 2 hours. This is his EKG. What’s your next move?
If you look at the anterior leads, you’ll notice upsloping ST depressions and tall, symmetric, prominent t waves. This pattern is known as De Winter’s T wave pattern. More importantly, it is a STEMI equivalent, highly suggestive and specific for LAD occlusion.
Activate the cath lab.
Don’t be reassured that your first troponin is negative. You may just have been fortunate enough to catch this early. Your repeat EKG may or may not show evolution to a traditional anterior STEMI. This current finding on EKG is enough to activate your friendly neighborhood cath lab though.
This t wave pattern was first described in 2008 by De Winter and Wellens (those guys are all about those t waves). It is estimated to represent about 2% of LAD occlusions. Since they are not whopping ST elevations on EKG, clinicians underdiagnose these.
Remember, the eye cannot see what the mind does not know. Now you know. Activate the cath lab.
Here’s a few more examples.