Several well-described ECG patterns signal an occluded coronary artery without meeting ST-elevation millimetre thresholds. Hyperacute T waves — broad-based, tall and symmetrical relative to the QRS — can be the earliest sign. The de Winter pattern shows upsloping ST depression at the J point with tall T waves in the precordial leads, classically with proximal LAD occlusion.
Posterior infarction shows as horizontal ST depression in V1–V3 with upright T waves; posterior leads V7–V9 confirm it. In inferior infarction, reciprocal ST depression in aVL may appear before the inferior elevation is obvious.
- Compare T-wave size with the QRS; a disproportionately large T wave may be hyperacute.
- Record V7–V9 when V1–V3 show ST depression in a patient with chest pain.
- Look at aVL for new ST depression when inferior leads look borderline.
- Recognise the de Winter pattern as an occlusion equivalent, not as NSTEMI.
- Serial ECGs catch evolving changes a single trace misses.
Why it matters
These patterns are recognisable at the bedside, and each one changes where the patient goes next.
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