ECG patterns

De Winter Pattern

The de Winter pattern is seen in ~2% of acute LAD occlusions and is often under-recognised by clinicians

Key diagnostic features include ST depression and peaked T waves in the precordial leads

• Tall, prominent, symmetrical T waves in the precordial leads

• Upsloping ST segment depression > 1mm at the J point in the precordial leads

• Absence of ST elevation in the precordial leads

• Reciprocal ST segment elevation (0.5mm – 1mm) in aVR

• Typical STEMI morphology may precede or follow the De Winter pattern

Brugada Criteria (for diagnosing VT vs SVT with aberrancy)

Step-by-step Brugada Criteria (for wide-complex tachycardia):

1. Absence of typical RBBB or LBBB morphology → = VT

2. Positive or Negative concordance throughout the precordial leads → = VT

3. Very broad complexes > 160ms → = VT

4. AV dissociation visible? (P waves unrelated to QRS) → = VT

5. Extreme axis deviation (“northwest axis”) → = VT

6. Capture beats: Occur when the sinoatrial node transiently “captures” the ventricles in the midst of AV dissociation, producing a QRS complex of normal duration→ = VT

7. Fusion beats: Occur when a sinus and ventricular beat coincide to produce a hybrid complex → = VT

Brugada Syndrome (channelopathy associated with sudden cardiac death)

ECG: Look in leads V1–V3

• Type 1 Brugada: Coved ST elevation ≥2 mm in ≥1 of V1–V3 followed by an inverted T wave

• Type 2 or 3 are "saddle-back" patterns (less diagnostic)

Sgarbossa Criteria (STEMI in the presence of LBBB or paced rhythm)

Original Sgarbossa Criteria:

Positive finding in any criteria is suggest OMI

1. Concordant ST elevation ≥1 mm in leads with a positive QRS (5 points)

2. Concordant ST depression ≥1 mm in V1–V3 (3 points)

3. ST Elevation at the J-point, relative to QRS onset, is at least 1 mm AND has an amplitude at least 25% of the preceding S-wave

   An ST/S ratio of 0.20 is also very high and almost as specific as a 0.25 ratio

Sokolow–Lyon Criteria (for Left Ventricular Hypertrophy – LVH)

• Measure S wave in V1

• Measure R wave in V5 or V6 (whichever is taller)

Positive for LVH if:

• S in V1 + R in V5 or V6 ≥35 mm

• OR R wave in aVL ≥11 mm