Posterior Myocardial Infarction, or deWinter T Waves?
May 15, 2022 2 minutes read
By Ken Grauer, MD
Professor Emeritus in Family Medicine, College of Medicine, University of Florida
The ECG below was taken from an older man who complained of chest pain over the past month. The pain severity was even worse on the day he underwent imaging. How would you interpret this ECG?
The rhythm is atrial fibrillation with a controlled ventricular response. Voltage is lower in the limb leads. There are inferior Q waves and a predominant (albeit small) R wave in lead V1. The most remarkable finding relates to the marked ST-T wave abnormalities. This case is complex, with many factors to consider. Perhaps the most important factor is the history of ongoing symptoms for a month, which worsened the day this ECG was obtained.
The principal differential diagnosis for this case is suggested in the title of this post: consideration of posterior infarction, or impending anterior infarction with deWinter T waves. The term deWinter T waves refers to the ECG finding of giant T waves visible in at least several anterior leads in a patient with recent symptoms. Often, there is some J-point ST depression, followed by a steeply rising ascending limb of the huge T wave. Clinically, in a patient with new chest pain, deWinter T waves suggest impending or acute occlusion of the left anterior descending coronary artery.
The ECG picture here is much more consistent with infero-postero infarction that is not acute — but which probably occurred a number of days, perhaps even a week, before this ECG was obtained. Inferior lead Q waves and the predominant R wave in lead V1 establish the fact infero-postero infarction has occurred. Inferior lead ST elevation is relatively modest, considering the deep T wave inversion. This is a typical ECG finding of inferior infarction that has evolved and now is showing “reperfusion T waves.”
The horizontal “ledge-like” depressed ST segments in the chest leads look nothing like the steep-rising ascending limb of giant deWinter T waves. T wave peaking in the anterior leads is the mirror image of what would be seen as deep T wave inversion in posterior leads, therefore completely consistent with the concept of “reperfusion T waves” occurring in the posterior wall distribution. Cardiac catheterization revealed a mid-right coronary artery lesion, consistent with infero-postero infarction that probably occurred several days earlier.
For more information about and further discussion on this case, please click here.
The ECG was taken from an older man who complained of chest pain over the past month. The pain severity was even worse on the day he underwent imaging. How would you interpret the ECG?
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