The same occlusion has declared itself as ST elevation

The artery has reperfused and the segments are recovering

The earlier pattern was a false alarm and this is the real event

A second, new occlusion has occurred in a different artery

Central chest pain for forty minutes, still present

Smokes fifteen a day, no other history and no medication. Father died of a heart attack at 46. The paramedic tracing was transmitted and reported as no ST elevation, so he was brought to the emergency department rather than straight to the catheter laboratory.

Stage 1 of 2

Kwabena Mensah is sweating and restless on the trolley, describing a heavy band across his chest that has not eased since it began. Pulses are equal, chest clear, no murmur. The first troponin is pending. This tracing was recorded four minutes after he arrived.

Tracing 1 of 2 for the quiz “Central chest pain for forty minutes, still present”. — Twelve-lead on arrival, 25 mm/s, 10 mm/mV. Open this tracing in the studio

What is on this tracing?

ADeep symmetric T-wave inversion in V2 to V4 Your answer
BConcave ST elevation with J-point notching Your answer
CUpsloping ST depression with tall symmetric T waves across the praecordial leads Correct answer Your answer
DPeaked T waves on a narrow base with a broadening QRS Your answer

The praecordial leads show ST segments that slope upward from the J point into tall, peaked, symmetric T waves, with ST depression of about 1 to 2 mm at the J point across V1 to V6. This is the de Winter pattern, a recognised STEMI equivalent. Deep symmetric T-wave inversion would point to Wellens syndrome, which has a different morphology. Concave ST elevation with J-point notching describes benign early repolarisation. The T waves here are tall and symmetric rather than narrow-based and peaked as in hyperkalaemia, and the QRS is not broad.

What does that commit you to?

AThrombolyse in the department Your answer
BActivate the primary PCI pathway now Correct answer Your answer
CWait for the three-hour troponin before deciding Your answer
DTreat as an NSTEMI, with angiography within 72 hours Your answer

The de Winter pattern represents acute proximal LAD occlusion and is treated as a STEMI equivalent, so it requires emergent reperfusion. The primary percutaneous coronary intervention pathway should be activated immediately. Waiting for a troponin result delays reperfusion when the ECG has already made the diagnosis. Treating this as an NSTEMI with angiography within 72 hours would leave the artery occluded. Thrombolysis in the department is an option only where primary PCI is not available within guideline timeframes, and the vignette does not state that.

Stage 2 of 2

Twenty-five minutes later he is still in the department and the pain is worse. The tracing is repeated. His first troponin has come back at 34 ng/L.

Tracing 2 of 2 for the quiz “Central chest pain for forty minutes, still present”. — Twelve-lead repeated twenty-five minutes later, 25 mm/s, 10 mm/mV. Open this tracing in the studio

Observations

HR: 98
SpO₂ (%): 96
Respiratory rate: 22
Temperature (°C): 36.5
Systolic BP (mmHg): 118
Diastolic BP (mmHg): 72

Bloods

Troponin T (ng/L): 34

What has changed?

AThe same occlusion has declared itself as ST elevation Correct answer Your answer
BThe artery has reperfused and the segments are recovering Your answer
CThe earlier pattern was a false alarm and this is the real event Your answer
DA second, new occlusion has occurred in a different artery Your answer

The praecordial leads now show frank ST elevation of several millimetres in V1 to V6 with reciprocal depression in the inferior leads. This is the same proximal LAD occlusion that produced the de Winter pattern twenty-five minutes earlier, now presenting as conventional anterior STEMI. The territory and the clinical continuity confirm it is one evolving event rather than a second occlusion. Reperfusion would show ST resolution and terminal T-wave inversion, not new elevation.

Diagnosis

Acute proximal LAD occlusion with a de Winter pattern

The de Winter pattern is a STEMI equivalent that represents acute proximal left anterior descending artery occlusion. It is characterised by upsloping ST depression merging into tall, symmetric T waves across the praecordial leads, typically with subtle ST elevation in aVR. Automated interpretation algorithms and triage criteria that require ST elevation will miss it, which is exactly what happened here: the paramedic tracing was reported as no ST elevation and the patient was brought to the emergency department instead of straight to the catheter laboratory.

Recognising this pattern on the first tracing would have saved the twenty-five minutes it took for the occlusion to declare itself as conventional ST elevation. The practical lesson is that a patient with ongoing ischaemic pain and praecordial ST depression with tall T waves needs the catheter laboratory just as urgently as one with ST elevation.

References

de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008;359(19):2071-2073.
Verouden NJ, Koch KT, Peters RJ, et al. Persistent precordial "hyperacute" T-waves signify proximal left anterior descending artery occlusion. Heart. 2009;95(20):1701-1706.

Central chest pain for forty minutes, still present

The case

On arrival

Observations

Bloods

Diagnosis

References

Discussion