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 RS complex in all precordial leads (V1–V6)? → If yes = VT

2. If RS is present: Is the RS interval >100 ms in any precordial lead? → If yes = VT

3. AV dissociation visible? (P waves unrelated to QRS) → If yes = VT

4. Are there VT-specific morphology patterns in V1/V2 or V6? → If yes = VT

→ If any of these steps are positive, VT is likely.

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:

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. Discordant ST elevation ≥1 mm AND ≥25% of the preceding S-wave depth

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