EKG of the Week 2019 8-25

This EKG comes courtesy of Dr. Conor Russell.

 

58 year old male with PMHx of HTN presented to the ED for diffuse chest pain, 8/10, associated with nausea. Onset 20 minutes prior to arrival while he was mowing the lawn. The patient was given 2 sublingual nitro’s by EMS with no symptomatic relief.

 VS T 98.4, HR 70, BP 149/92, RR 20, SpO2 99%

 Patient was ill appearing, diaphoretic and clutching his chest. 

 

His EKG is below.

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1.     What does the EKG demonstrate?

2.     How would you manage this patient?

ANSWER:

The EKG shows slight ST depressions with tall T waves in the anterior leads. This is known as deWinter’s T waves.

 This pattern should be recognized as a STEMI equivalent and the patient should have urgent reperfusion.

 

Hyperacute T waves have long been described as an early finding in acute MI’s. This finding typically evolves into ST elevations.

In 2008 deWinter described an EKG pattern similar to hyperacute T waves that often persisted and never evolved into frank ST elevations. The pattern was noted in 2% of patients with anterior wall MI’s who were found to have 100% LAD occlusions on cath.  The EKG pattern they noticed was, “1-3 mm upsloping ST segment depression at the J point in leads V1-V6 that continues into tall positive symmetrical T waves” (de Winter et al. N Engl J Med 2008;359:2071). There was often associated 1-2mm ST elevations in lead aVR. They recommend that, “Ambulance staff, emergency physicians, cardiologists and other caregivers involved in STEMI networks should familiarize themselves with these sometimes subtle ECG changes. …practitioners should not miss the important finding of the ECG pattern described above to avoid potential delay in treatment” (de Winter et al. Journal of Electrocardiology. 2016; 49:76–80).

 Our patient’s EKG demonstrates slight ST depressions in leads V2-V6 with tall T waves in these leads. (There are also slight ST depressions in leads II, III and aVF). There is slight ST elevation in lead aVR. At the insistence of the brand new ED attending Dr. Russell, the patient was taken to the cath lab and found to have a 100% proximal LAD occlusion. Stents were placed.

Hyperacute T waves from acute ischemia can be difficult to distinguish from peaked T waves seen in hyperkalemia. One article suggests that hyperacute T waves are “asymmetric with a broad base” (Brady et al. J Accid Emerg Med 2000;17:40–45). However, peaked T waves in hyperkalemia are, “tall, narrow, and peaked with a prominent or sharp apex, and are symmetrical” (Brady et al. J Accid Emerg Med 2000;17:40–45).