Ischaemia and infarction
De Winter T waves
Upsloping ST depression with tall symmetrical T waves in the chest leads — an LAD equivalent without the elevation.
What you see
- Upsloping ST depression of 1–3 mm at the J point in V1–V6.
- Tall, broad, symmetrical T waves rising straight out of the depressed segment.
- Frequently 1–2 mm of ST elevation in aVR.
- No ST elevation in the chest leads at all.
Why it looks like that
A static pattern seen with acute proximal LAD occlusion in perhaps 2% of cases. The prevailing explanation is that endocardial ischaemia is not accompanied by the usual epicardial injury current, so the ST vector never lifts — the tall T waves carry the message instead.
What to do
- Treat as a STEMI equivalent: immediate discussion with the cath lab.
- Do not wait for the pattern to evolve into ST elevation — often it never does.
- Serial ECGs while awaiting transfer, since the pattern can convert.
The trap
It fails every automated STEMI criterion, so the machine reads 'non-specific ST-T changes'. This is a pattern you have to recognise by eye or not at all.
More in ischaemia and infarction
Anterior STEMI
Convex ST elevation across the anterior chest leads — the LAD occlusion you cannot afford to sit on.
Inferior STEMI
ST elevation in II, III and aVF with reciprocal change in aVL — and a right ventricle you must check before giving nitrates.
Posterior myocardial infarction
Tall R waves and ST depression in V1–V3 — a STEMI viewed from behind, and easy to call NSTEMI by mistake.
Wellens' syndrome
Deep or biphasic T waves in V2–V3 in a pain-free patient — critical LAD stenosis waiting to declare itself.