• De Winter’s T waves
  • Anterior STEMI equivalent.
  • Indicative of early or evolving proximal left anterior descending (LAD) occlusion.
  • ECG: Upsloping ST-segment depression (STD) in V1-V6 with prominent and symmetrical T-wave.
• Wellens’ syndrome
  • Anterior STEMI equivalent.
  • Indicative of critical stenosis of the proximal LAD and imminent anterior infarct.
  • ECG: Symmetrical T waves with deep inversion or biphasicity in V2-V3.
• ST-elevation in lead aVR
  • Anterior STEMI equivalent.
  • Indicative of proximal left main (LM) or left anterior descending coronary artery occlusion; or subendocardial ischemia due to subtotal occlusion or triple vessel disease; or a repolarization abnormality.
  • ECG: ST-elevation >1mm in aVR with reciprocal anterolateral STD suggests LM or LAD occlusion, whereas without reciprocal STD is more suggestive of subtotal. occlusion (ie: demand etiology or triple vessel disease).
• Acute MI in the presence of Left Bundle Branch Block (LBBB)
  • New LBBB is no longer considered a STEMI equivalent.
  • Several tools have been developed to help identify ischemia and diagnose STEMI in patients with LBBB or ventricular paced rhythms.
    • Sgarbossa Criteria (1996) – A highly specific, but insensitive point scoring system with 3 criteria (concordant STE, concordant STD, and excessive discordance).
    • Smith-Modified Sgarbossa Criteria (2012) – Improved the sensitivity and diagnostic accuracy by changing the 3^rd criteria to a ratio rather than a measurement and eliminating the point scoring.
    • BARCELONA Criteria (2020) – Further improved the sensitivity and diagnostic accuracy with changes to both the 2^nd and 3^rd.

De Winter’s T waves

• Background:
  • Anterior STEMI equivalent indicative of an early or evolving proximal LAD occlusion.
• History and Physical:
  • Findings suggestive of acute coronary syndrome (ACS).
• ECG findings:
  • Concave upsloping STD (>1mm) in V₁to V₆ with prominent symmetrical T waves.
  • Reciprocal 1-2mm STE in aVR is common.
  • QRS complexes are usually normal or slightly wide.
  • Loss of R-wave progression can occur.

The following table compares De Winter’s T-waves to non-ischemic STE and STEMI:

(Photos adopted from Rawshani 2017)

• Recommended Treatment:
  • Treat as ACS; these lesions result in extensive anterior infarction and patients require urgent cardiology consultation and revascularization intervention.

Wellens’ syndrome (aka “The Widow Maker”)

• Background:
  • Anterior STEMI equivalent with high specificity for critical stenosis of the proximal LAD.
• History and Physical:
  • Patients are typically pain-free at the time of ECG and will have normal or mildly elevated biomarkers.
• ECG findings:
  • Symmetrical deeply inverted (Type A) or Biphasic (Type B) T-waves in V2 & V3,
  • No STE (<1 mm when measured at the J-point),
  • No precordial Q waves, and
  • Normal R wave progression (R amplitude in V3 >3mm).

• Recommended Treatment:
  • Treat as ACS and patients require admission, urgent Cardiology consultation, and revascularization as they are at extreme risk (~75% in <2weeks) of developing massive anterior infarction.

ST-elevation in lead aVR

• Background:
  • aVR was designed to evaluate the right upper heart (RV outflow tract & basal interventricular septum).
  • STE >1mm in aVR may represent:
    • a STEMI equivalent indicating occlusion of the left main (LM) or proximal LAD arteries; or
    • widespread subendocardial ischemia due to near-total LM occlusion, triple vessel disease, or demand etiology; or
    • a repolarization abnormality due to LVH or electrolyte imbalances.
• History and Physical:
  • Findings suggestive of ACS.
• ECG findings:
  • STE in aVR >1mm with diffuse reciprocal STD indicates acute LM or proximal LAD occlusion. The following ECG depicts an acute LM occlusion with STE in aVR (blue arrow) and concomitant diffuse reciprocal ST-depressions:

• • STE in aVR >1mm without diffuse STD can also indicate proximal occlusion, but is more likely secondary to widespread subendocardial ischemia due to severe nonocclusive LM disease, triple vessel disease, or demand etiology (i.e., tachycardia, hypo-or hypertension, aortic stenosis, etc.)
  • STE in aVR >1mm in the presence of tachycardia is almost always due to a supply-demand mismatch and not suggestive of LM occlusion.
  • STE in aVR > V1 usually differentiates LM from proximal LAD occlusion.

• Recommended Treatment:
  • Recognizing this finding is critical because the LM supplies ~75% of the LV myocardium and its occlusion would result in significant mortality.
  • LM occlusions are heterogeneric and may also present with concomittent anterolateral ST elevation or ischemia-induced conduction disturbances.

Acute MI in the presence of LBBB:

• Background:
  • A new LBBB is no longer recognized as STEMI equivalent or indication for revascularization, but guidelines still suggest they be carefully considered and interpreted in clinical context.
  • Several clinical decision tools have been developed to help identify ischemia and diagnose acute MI in patients with abnormal repolarization due to LBBB or ventricular pacing.
• The Original Sgarbossa Criteria (1996)
  • ≥ 3 points are required to diagnose acute myocardial infarction (Sn 36%; Sp 96%):
    • Criterion 1: Concordant STE ≥ 1mm in any lead with a (+) QRS (5 points).
    • Criterion 2: Concordant STD >1mm in V1-V3 (3 points).
    • Criterion 3: Excessive discordance (≥ 5 mm) in any lead with STE (2 points).
  • Overall use was limited by poor sensitivity and inability to rule out ischemia.
• The Smith-Modified Sgarbossa Criteria (2012)
  • Made two major changes to improve sensitivity and offer better diagnostic accuracy (Sn 90%; Sp 90%):
    • Point scoring was eliminated which allowed for the diagnosis of MI to be made if any of the criterion were met.
    • The 3^rd criterion measuring excessive ST discordance would use an ST/S ratio >25% rather than the arbitrary >5mm cut-off used by the original.

• The BARCELONA Criteria (2020)
  • Further improved sensitivity and diagnostic accuracy (Sn 93%; Sp 94%) by changing both the 2^nd and 3^rd.
    • Criterion 1: (unchanged) Concordant STE > 1mm in any lead with a (+) QRS.
    • Criterion 2: Concordant STD >1mm in any lead (instead of relying on just V1-V3 per the Smith-modified Criteria).
    • Criterion 3: Excessive discordance was changed to use ST deviation ≥ 1mm in any lead where the dominant R or S is ≤ 6mm (instead of using the ST/S ratio >25% per the Smith-modified Criteria). This change now allowed for assessment of leads when they are low voltage.
  • The BARCELONA criteria have not yet been externally validated.

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