Several ECG patterns signal an acutely occluded coronary artery without meeting standard ST-elevation thresholds. Hyperacute T waves — broad, tall and symmetrical relative to the QRS — can precede ST elevation. The de Winter pattern shows upsloping ST depression with tall T waves in the precordial leads. Posterior occlusion appears as ST depression maximal in V1 to V4, and posterior leads V7 to V9 can confirm it.
In a patient with ongoing ischaemic pain, repeat the ECG every 15 to 30 minutes, compare with old tracings, and discuss with cardiology early when any of these appear.
- Look for hyperacute T waves: broad-based, bulky and tall relative to the QRS.
- Recognise the de Winter pattern: upsloping ST depression with tall, symmetrical precordial T waves.
- ST depression maximal in V1–V4 may be posterior occlusion; record V7–V9.
- Repeat the ECG every 15–30 minutes while pain continues and compare with old tracings.
- Refractory ischaemic pain despite treatment warrants urgent angiography whatever the ECG shows.
Why it matters
Patients with occlusion but no ST elevation wait longer for reperfusion.
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