The document discusses De Winter's T waves, which are characterized by three key findings on ECG: upsloping ST depression in precordial leads, tall symmetric T waves in precordial leads, and ST elevation in aVR. It also summarizes the ECG patterns seen in dextrocardia, including right axis deviation, positive complexes in aVR, and dominant S waves in precordial leads. Finally, it outlines the ECG features of digoxin effect and toxicity, such as biphasic T waves, shortened QT, and the dysrhythmia of supraventricular tachycardia with a slow ventricular response seen in digoxin toxicity.

1. Domina Petric, MD
ECG D

2. De Winter’s T waves
Burns E. De Winter´s T Waves (November 16, 2017). Retrieved from
https://lifeinthefastlane.com/ecg-library/de-winters-t-waves/
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3. De Winter’s T waves
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4. Diagnostic criteria
• Tall, prominent, symmetric 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!
• ST segment elevation (0,5-1 mm) in aVR!
• STEMI morphology may precede or follow De
Winter pattern!
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5. De Winter´s T waves
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Subtle ST elevation in aVR (>0.5mm).
Upsloping ST depression in the precordial leads (>1mm at J-point).
Peaked anterior T waves in V2-V6.

6. Dextrocardia
Nickson C. Dextrocardia (April 7, 2017). Retrieved from
https://lifeinthefastlane.com/ecg-library/basics/dextrocardia/
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7. Dextrocardia
• Right axis deviation!
• Positive QRS complexes (with upright P and
T waves) in aVR!
• Lead I: inversion of all complexes (inverted P
wave, negative QRS, inverted T wave)!
• Absent R-wave progression in the chest
leads (dominant S waves throughout)!
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8. Dextrocardia
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Right axis deviation
Positive QRS in aVR
Inverted P, T wave and QRS in DI
Dominant S waves in precordial leads

9. Digoxin effect
Burns E. Digoxin Effect (April 5, 2017). Retrieved from
https://lifeinthefastlane.com/ecg-library/digoxin-effect/
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10. Digoxin effect
• Down-sloping ST depression with a characteristic
“Salvador Dali sagging” appearance!
• Flattened, inverted or biphasic T waves.
• Shortened QT interval.
• Mild PR interval prolongation due to increased vagal
tone up to 240 ms.
• Prominent U waves.
• Peaking of the terminal portion of the T waves.
• J point depression.
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11. Digoxin effect
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Biphasic T waves and
superimposed U waves

12. Digoxin toxicity
Burns E. Digoxin Toxicity (April 4, 2017). Retrieved from
https://lifeinthefastlane.com/ecg-library/basics/digoxin-toxicity/
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13. Digoxin toxicity
Dysrhythmias are usually due to:
• increased automaticity (increased intracellular calcium)
• decreased AV conduction (increased vagal effects at the
AV node)
The classic dysrhythmia associated with digoxin
toxicity is the combination of:
• supraventricular tachycardia (due to increased
automaticity)
• slow ventricular response (due to decreased AV
conduction)
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14. Digoxin toxicity
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15. ECG
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Atrial fibrillation with complete AV block!

16. Literature