Chest pain: the bread and butter of emergency medicine. We see so many of these that it can be mind-numbing, and for EXACTLY that reason it’s critical to recognize those weird EKGs that aren’t an obvious STEMI but can signal a coronary occlusion.

One of the less-talked-about danger signs on EKG is “de Winter’s waves“, which is thought to represent acute LAD occlusion (similar to the more commonly known Wellen’s criteria):

  •  Tall, symmetric T waves in precordial leads
  • Upsloping ST segment depression in precordial leads (no ST elevation)
  • May have subtle ST elevation in aVR
  • T waves are often taller than the QRS

These waves can look similar to the peaked T waves seen in hyperkalemia, but are typically isolated to the precordial leads, and that’s the tipoff.

de Winter’s waves should be considered a STEMI equivalent, and the patient should be taken for urgent cath or considered for thrombolysis if cath is not available.

Take a look at several examples below. Would you recognize these as a STEMI?

Example 1

dewinter t waves 1

Example 2

deWinter t waves 2

And this last is a particularly subtle (likely) example from Dr. Smith’s ECG Blog ( Note the sagging T waves in v3 and v4, and tall T waves in v2/3 are clearly visible that outsize the associated QRS. This patient was unfortunately discharged after one negative troponin and was found dead 12 hours later. Read the full case here.

Example 3

Adapted from Life in the Fast Lane and Dr. Smith’s ECG Blog.