De Winter et al. in 2008 described a new electrocardiographic sign of proximal LAD occlusion, that consists of ST segment upsloping depression at the J point in leads V1 to V6 that continued into tall, positive symmetrical T waves, that has been associated with the occlusion of the proximal left anterior descending artery (LAD).
This pattern was recognised in 2% of the patients with anterior myocardial infraction, and it was persisting from the first ECG obtained until the preprocedural ECGs, in contrast to hyperacute T waves that have been recognized as a transient early feature that changes into ST elevation. On coronary angiography, the culprit lesion was the proximal LAD artery, and a ‘wraparound’ LAD artery was present in approximately 50% of patients.
The electrophysiological explanation of this ECG pattern remains unclear. Hypothetically an anatomical variant of the Purkinje fibers, with endocardial conduction delay, could be present. An alternative explanation is that the absence of ST elevation may be related to the lack of activation of sarcolemmal ATP-sensitive potassium channels by ischemic ATP depletion.
1. Verouden NJ, Koch KT, Peters RJ, et al. Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion. Heart 2009;95(20):1701–6
2. De Winter RJ, Verouden NJW, Wellens HJJ, Wilde AAM. A New ECG Sign of Proximal LAD Occlusion. N Engl J Med 2008;359(19):2071–3.
3. De Winter RW, Adams R, Verouden NJW, de Winter RJ. Precordial junctional ST-segment depression with tall symmetric T-waves signifying proximal LAD occlusion, case reports of STEMI equivalence. J Electrocardiol 2016;49(1):76–80.
4. Montero Cabezas JM, Karalis I, Schalij MJ. De Winter Electrocardiographic Pattern Related with a Non-Left Anterior Descending Coronary Artery Occlusion. Ann Noninvasive Electrocardiol 2016;21(5):526–8.