Anterior STEMI Evolves to de Winter’s T-waves

A middle-aged man called EMS for chest pain.

This prehospital ECG was recorded:

Obvious Anterior STEMI due to proximal LAD occlusion (with STE in aVL and reciprocal STD in inferior leads).

On arrival to the ED, this ECG was recorded 10 minutes later:

Almost all STE is gone, but the hyperacute T-waves remain

While waiting for the cath team, this was recorded 30 minutes after 2nd ECG:

Now there are classic de Winter’s T-waves.

This shows the dynamic nature of coronary thrombus.  Presumably, the thrombus had autolysis to a very small degree, allowing a trickle of blood flow through the LAD, enough to eliminate the ST elevation.

The patient was found to have a 100% proximal LAD occlusion.

By the time of the angiogram, which is never at the same the time as the ECG, there was not even a trickle of blood.

See this related post, with discussion of de Winter’s T-waves:

Is the LAD really completely occluded when there are de Winter’s waves?

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