ECG Surprise Attack!: de Winter Aches and Pains

  • Nicholas S. Fern
  • Amal MattuEmail author


There are some ECG patterns that are not classically considered as STEMIs but represent what can be called STEMI equivalents as they portend significant potential for progression to infarctions. The de Winter ECG pattern is an electrocardiographic pattern found in some patients presenting with ischemic chest pain. The pattern is associated with acute proximal LAD occlusion lacking anterior STE on ECG and places the patient at considerable risk for progression to an extensive anterior wall myocardial infarction.


deWinter EKG  STEMI equivalent  Chest pain 


Disclosure Statement

The authors of this chapter report no significant disclosures.


  1. 1.
    Verouden NJ, Koch KT, Peters RJ, et al. Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion. Heart. 2009;95(20):1701–6. Scholar
  2. 2.
    Lipinski MJ, Mattu A, Brady WJ. Evolving electrocardiographic indications for emergent reperfusion. Cardiol Clin. 2018;36(1):13–26. Scholar
  3. 3.
    de Winter RW, Adams R, Verouden NJW, de Winter RJ. Precordial junctional ST-segment depression with tall symmetric T-waves signifying proximal LAD occlusion, case reports of STEMI equivalents. J Electrocardiol. 2016;49(1):76–80. Scholar
  4. 4.
    Goebel M, Bledsoe J, Orford JL, Mattu A, Brady WJ. A new ST-segment elevation myocardial infarction equivalent pattern? Prominent T wave and J-point depression in the precordial leads associated with ST-segment elevation in lead aVR. Am J Emerg Med. 2014;32(3):287.e5–8. Scholar
  5. 5.
    Rokos IC, French WJ, Mattu A, et al. Appropriate cardiac cath lab activation: optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction. Am Heart J. 2010;160(6):995–1003.e8. Scholar
  6. 6.
    Hennings JR, Fesmire FM. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med. 2012;30(6):994–1000. Scholar
  7. 7.
    Birnbaum Y, Bayés De Luna A, Fiol M, et al. Common pitfalls in the interpretation of electrocardiograms from patients with acute coronary syndromes with narrow QRS: a consensus report. J Electrocardiol. 2012;45(5):463–75. Scholar
  8. 8.
    Lawner BJ, Nable JV, Mattu A. Novel patterns of ischemia and STEMI equivalents. Cardiol Clin. 2012;30(4):591–9. Scholar
  9. 9.
    Gorgels APM. ST-elevation and non-ST-elevation acute coronary syndromes: should the guidelines be changed? J Electrocardiol. 2013;46(4):318–23. Scholar
  10. 10.
    Ibanez B, James S, Agewall S, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39(2):119–77. Scholar
  11. 11.
    Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):e139–228. Scholar
  12. 12.
    O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of st-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):78–140. Scholar
  13. 13.
    de Winter RJ, Verouden NJW, Wellens HJJ, Wilde AAM. A new ECG sign of Ppoximal LAD occlusion. N Engl J Med. 2008;359(19):2071–3. Scholar
  14. 14.
    Zhao YT, Wang L, Yi Z. Evolvement to the de Winter electrocardiographic pattern. Am J Emerg Med. 2016;34(2):330–2. Scholar
  15. 15.
    Montero-Cabezas JM, van der Kley F, Karalis I, Schalij MJ. The “De Winter Pattern” can progress to ST-segment elevation acute coronary syndrome. Response. Rev Esp Cardiol (Engl Ed). 2015;68(11):1043. ER.CrossRefGoogle Scholar
  16. 16.
    Fiol Sala M, Bayés de Luna A, Carrillo López A, García-Niebla J. The “De Winter Pattern” can progress to ST-segment elevation acute coronary syndrome. Rev Española Cardiol (English Ed). 2015;68(11):1042–3. Scholar
  17. 17.
    Ayer A, Terkelsen CJ. Difficult ECGs in STEMI. J Electrocardiol. 2014;47(4):448–58. Scholar
  18. 18.
    Li RA, Leppo M, Miki T, Seino S, Marbán E. Molecular basis of electrocardiographic ST-segment elevation. Circ Res. 2000;87(10):837–9.CrossRefGoogle Scholar
  19. 19.
    Zafari AM. Myocardial infarction: practice essentials, background, definitions. Published 2018. Accessed 24 June 2018.
  20. 20.
    Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 124; 2011.
  21. 21.
    Morris NP, Body R. The de Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. Eur J Emerg Med. 2017;24(4):236–42. Scholar
  22. 22.
    Nikus K, Pahlm O, Wagner G, et al. Electrocardiographic classification of acute coronary syndromes: a review by a committee of the International Society for Holter and Non-Invasive Electrocardiology. J Electrocardiol. 2010;43(2):91–103. Scholar
  23. 23.
    de Zwaan C, Bär FWHM, Wellens HJJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103(4 PART 2):730–6. Scholar
  24. 24.
    Scirica BM. Acute coronary syndrome. Emerging tools for diagnosis and risk assessment. J Am Coll Cardiol. 2010;55(14):1403–15. Scholar
  25. 25.
    Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Eur Heart J. 2012;33(20):2551–67. Scholar
  26. 26.
    Macias M, Peachey J, Mattu A, Brady WJ. The electrocardiogram in the ACS patient: high-risk electrocardiographic presentations lacking anatomically oriented ST-segment elevation. Am J Emerg Med. 2016;34(3):611–7. Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.The Queen’s Medical CenterHonoluluUSA
  2. 2.Department of Emergency MedicineUniversity of Maryland School of MedicineBaltimoreUSA

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