Chest pain, bifascicular block, and de Winter T-waves

EMS is called to a 82 year old male with a chief complaint of chest pain.

  • Onset: 30 minutes prior to EMS arrival
  • Provoke: Nothing makes the pain better or worse
  • Quality: Severe pressure
  • Radiate: The pain radiates to both arms
  • Severity: 6/10
  • Time: No previous episodes

Past medical history: Hypertension, including pulmonary hypertension

Medications: Aspirin, unknown antihypertensives

Vital signs:

  • HR: 60
  • RR: 20
  • BP: 120/73
  • SpO2: 96% on RA

Skin is cool, pale, and diaphoretic. The patient admits to mild dyspnea. He also admits to slight nausea but he has not vomited.

The cardiac monitor is attached.

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A 12 lead ECG is captured.

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Here is the 12 lead ECG obtained on arrival at the ED.

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The patient was sent to the cardiac cath lab where the left anterior descending (LAD) artery was found to be 100% occluded. It was successfully stented and the patient made a full recovery.

Discussion

This case study was originally published almost contemporaneously with an important article in the New England Journal of Medicine that described de Winter T-waves.

Although the initial ECG shows bifasicular block, we can see J-point depression with tall, symmetrical T-waves in the anterior leads.

Amal Mattu, M.D. (@amalmattu) used this ECG in a video about de Winter T-waves here.

You can see many other examples of de Winter T-waves here.

Reference

de Winter R, Verouden N, Wellens H, Wilde A. A New ECG Sign of Proximal LAD Occlusion. New England Journal of Medicine. 2008;359(19):2071-2073. doi:10.1056/nejmc0804737.

Further Reading

Bifascicular Blocks – What You Need To Know

De Winter ST/T-Waves

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