Several ECG patterns signal acute coronary occlusion without classic ST elevation. De Winter T waves: upsloping ST depression with tall symmetrical precordial T waves. Posterior MI: ST depression in V1 to V3 — record V7 to V9. Hyperacute T waves: broad, tall T waves out of proportion to the QRS. Wellens: biphasic or deeply inverted T waves in V2 to V3 in a pain-free patient, warning of critical LAD stenosis.
In left bundle branch block or paced rhythm, use the modified Sgarbossa criteria. When in doubt, repeat the ECG every 15 to 30 minutes and discuss early with cardiology.
- De Winter T waves.
- Isolated ST depression V1–V3: record posterior leads.
- Hyperacute T waves.
- Wellens pattern.
- Modified Sgarbossa criteria in LBBB or pacing.
Why it matters
Patients with these patterns miss reperfusion when STEMI criteria are the only trigger.
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