ECG criteria
- Upsloping ST-segment depression at the J point, usually ≥1 mm, predominantly in V2–V4, and may occur in other anterior precordial leads
- Depression morphology is upsloping, transitioning directly into a tall T wave without an isoelectric segment
- Tall, symmetrical T wave with a broad base in the same leads; its amplitude may exceed the R wave, but this is not a mandatory feature
- Diagnostically significant ST elevation in the anterior leads is usually absent; STEMI thresholds depend on sex, age, and lead: in V2–V3 — ≥1.5 mm in women, ≥2 mm in men aged 40 years and older, ≥2.5 mm in men younger than 40 years, in other leads — ≥1 mm; the absence of ST elevation is not a mandatory criterion for describing the pattern, as it may coexist with ST elevation in some leads during dynamic transformation
- A slight ST elevation is sometimes noted in aVR — this feature is non-specific and is not a mandatory or confirmatory criterion
- QRS is often narrow (not widened), with possible delayed R-wave progression in the precordial leads — ancillary, non-mandatory findings
- The pattern is unstable: it may transform into typical STEMI or regress on serial ECGs
What it looks like on ECG
Key zone — anterior precordial leads, maximally pronounced in V2–V4, though changes may also occur in other V1–V6 leads. At the J point, the ST segment is shifted downward, typically by 1–3 mm, with an upsloping depression morphology rather than horizontal or downsloping as seen in typical subendocardial ischemia — the trace immediately rises and transitions into the T wave without a pause at the baseline.
The T wave is tall, broad at the base, and symmetrical on both sides, giving it a "ballooned" appearance; sometimes its amplitude exceeds that of the R wave in the same lead, though this is not a mandatory feature and depends on the lead and baseline R-wave progression.
Changes in limb leads are variable and often minimal. A slight ST elevation in aVR is sometimes described, but this feature is non-specific, is not among the diagnostic criteria for the pattern, and should not be used to confirm it. QRS is typically narrow (normal duration), and delayed R-wave progression in the precordial leads or transition zone shift may be observed — these are ancillary, inconstant findings that may have other causes (prior infarction, hypertrophy, incorrect lead placement).
| Element | Parameter | Leads |
|---|---|---|
| ST segment | depression 1–3 mm, upsloping | usually V2–V4, potentially V1–V6 |
| T wave | tall, symmetrical, broad | same leads |
| aVR | possible slight ST elevation (non-specific) | aVR |
The pattern is dynamic: a repeat recording in 10–20 minutes may progress to classic ST elevation (STEMI) or regress if coronary blood flow is spontaneously restored, which is why serial ECG recording is of critical importance.
Mechanism
The pattern is frequently associated with acute coronary occlusion of the anterior wall of the left ventricle, though the exact electrophysiological mechanism remains incompletely understood. One proposed interpretation is that ST depression with tall T waves reflects an early phase of ischemic injury dominated by repolarization changes without significant transmural injury sufficient to cause classic ST elevation, or that it represents an intermediate variant between hyperacute T waves and typical ST elevation. The instability of the pattern (progression to STEMI or regression) is consistent with a dynamic, incomplete phase of ischemia, but definitive electrophysiological evidence for the mechanism is lacking.
Causes
- Most commonly — acute occlusion of the LAD, especially the proximal segment, though cases involving other segments have been described
- Potential association with disease in other coronary arteries and with dynamic ischemia without complete occlusion
- May occur transiently in the setting of coronary spasm or thrombosis with partial clot lysis
- The pattern is non-specific: mimics (electrolyte disturbances, normal variant) must be excluded and correlated with the clinical presentation
Differential diagnosis
- NSTEMI (standard ST depression) — depression is more often horizontal or downsloping, the T wave is not as tall and symmetrical, and there is no characteristic direct transition from ST to T
- Wellens' syndrome — tall biphasic or deeply inverted T waves in V2–V3 without significant ST depression; typically recorded in the pain-free phase in the setting of critical LAD stenosis; arterial patency cannot be determined from the ECG
- Hyperkalemia — tall, symmetrical T waves; differentiated based on clinical presentation, potassium levels, and the overall constellation of ECG findings (possible QRS widening, P-wave flattening), rather than solely on the presence or absence of ST depression
- Early repolarization — ST elevation rather than depression, absence of acute NSTE-ACS clinical presentation
- Hyperacute T waves in evolving STEMI — usually lacking such prominent upsloping ST depression, transitioning more rapidly into ST elevation
Clinical significance and management
The de Winter pattern is regarded as a high-risk ECG sign of potential acute coronary occlusion (OMI): it is not an independent formal STEMI criterion in ESC algorithms and does not prove occlusion on its own. Resting anginal pain, its dynamics, and hemodynamic instability increase the likelihood of acute occlusion and expedite decision-making, but they are not mandatory criteria of the pattern itself — it can be recorded even with a subtle clinical presentation.
In the presence of ongoing ischemia, instability, or dynamic ECG changes, immediate consultation with the interventional team and, as a rule, emergency coronary angiography are indicated, concurrently with the exclusion of mimics (electrolyte disturbances, normal variants) and standard ACS evaluation. Troponin levels should be assessed in parallel, but should not delay reperfusion in the presence of clinically evident ongoing ischemia.
Serial ECG recording every 10–15 minutes is mandatory, as the pattern may transform into typical ST elevation or regress with spontaneous recanalization — regression of changes does not mean the danger has passed, and the artery may reocclude.
Common interpretation errors
- Interpreting it as "conventional" ST depression in NSTE-ACS and referring the patient for a delayed invasive strategy instead of immediate evaluation
- Ignoring the morphology of ST depression — failing to notice the characteristic upsloping configuration that distinguishes the pattern from routine ischemic depression
- Excessive categoricity: treating the pattern as definitive proof of LAD occlusion without considering the clinical picture and other causes
- Confusion with Wellens' syndrome without accounting for the presence or absence of ST depression and the phase of the pain syndrome
- A single ECG recording without serial monitoring, leading to missed dynamic transformation of the pattern
1. Which ST-segment feature is characteristic of de Winter T waves?
Characterized by upsloping ST depression at the J point that transitions directly into a tall, symmetrical T wave without an isoelectric segment.
2. Which statement regarding the causes of the de Winter pattern is correct?
The pattern is more commonly associated with LAD occlusion, particularly proximal, but has also been described with other segments, other arteries, and in the absence of complete occlusion.
3. What is the appropriate management strategy when a patient presents with a convincing ACS clinical picture and the de Winter pattern on the ECG?
The pattern is regarded as a potential sign of acute coronary occlusion requiring immediate invasive evaluation without waiting for troponin results if ischemia persists clinically.
Frequently asked questions
Are De Winter waves a STEMI or NSTEMI?
Formally, there is no ST elevation. The pattern is considered a potential sign of acute myocardial infarction with acute coronary occlusion (OMI), and in the presence of convincing clinical symptoms, the management strategy is the same as for STEMI—emergency evaluation for revascularization.
How to distinguish De Winter waves from Wellens' syndrome?
De Winter's sign presents with upsloping ST-segment depression and tall, prominent T waves, usually during ongoing chest pain, and is suspicious for acute occlusion. Wellens' syndrome is characterized by biphasic or deeply inverted T waves in V2–V3 without significant ST depression, typically recorded in the pain-free phase in the setting of critical LAD stenosis; both variants require urgent evaluation.
Is emergency coronary angiography required for this pattern?
In the presence of persistent ischemic chest pain, instability, or dynamic ECG changes, the pattern is considered an indication for immediate invasive evaluation without waiting for troponin results, while simultaneously ruling out mimics.
Can the de Winter pattern disappear on its own?
Yes, with spontaneous partial restoration of coronary blood flow, it may regress or transform into typical ST elevation, which is why serial ECG recordings are necessary.
In which leads should you look for De Winter waves?
The main changes usually occur in the anterior precordial leads, being most pronounced in V2–V4. Changes in limb leads are variable, and ST elevation in aVR is not a diagnostic criterion for this pattern.
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Related terms
More in the section "Ischemia and Myocardial Infarction"
Sources
- Surawicz B., Knilans T. Chou's Electrocardiography in Clinical Practice
- ESC Guidelines for the management of acute coronary syndromes, 2023
- Goldberger A. Clinical Electrocardiography: A Simplified Approach
Educational material for medical students and physicians. Does not replace clinical guidelines and physical examination; the ECG must always be interpreted in conjunction with the clinical picture.