Chest pain, bifascicular block, and de Winter T-waves

EMS is called to a 82 year old male with a chief complaint of chest pain.

  • Onset: 30 minutes prior to EMS arrival
  • Provoke: Nothing makes the pain better or worse
  • Quality: Severe pressure
  • Radiate: The pain radiates to both arms
  • Severity: 6/10
  • Time: No previous episodes

Past medical history: Hypertension, including pulmonary hypertension

Medications: Aspirin, unknown antihypertensives

Vital signs:

  • HR: 60
  • RR: 20
  • BP: 120/73
  • SpO2: 96% on RA

Skin is cool, pale, and diaphoretic. The patient admits to mild dyspnea. He also admits to slight nausea but he has not vomited.

The cardiac monitor is attached.


A 12 lead ECG is captured.


Here is the 12 lead ECG obtained on arrival at the ED.


The patient was sent to the cardiac cath lab where the left anterior descending (LAD) artery was found to be 100% occluded. It was successfully stented and the patient made a full recovery.


This case study was originally published almost contemporaneously with an important article in the New England Journal of Medicine that described de Winter T-waves.

Although the initial ECG shows bifasicular block, we can see J-point depression with tall, symmetrical T-waves in the anterior leads.

Amal Mattu, M.D. (@amalmattu) used this ECG in a video about de Winter T-waves here.

You can see many other examples of de Winter T-waves here.


de Winter R, Verouden N, Wellens H, Wilde A. A New ECG Sign of Proximal LAD Occlusion. New England Journal of Medicine. 2008;359(19):2071-2073. doi:10.1056/nejmc0804737.

Further Reading

Bifascicular Blocks – What You Need To Know

De Winter ST/T-Waves

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