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    4.4
    Home > ECG findings

    4.4

    Minnesota Code 4-4: J-point depression ≥ 1 mm with up-sloping ST — usually less specific, but watch for the de Winter pattern.

    Code 4.4 — Minnesota Code 4-4: J-point depression with up-sloping ST segment. The J point is depressed by 1.0 mm or more, but the ST segment then rises (up-sloping) or is U-shaped and returns towards the baseline. This "junctional" depression is common during a fast heart rate and is generally considered less specific for ischaemia than horizontal or down-sloping depression. The Minnesota Code counts it as a minor abnormality.

    Minnesota Code 4Up-sloping STMinor ST change
    ST-J depression≥ 1.0 mm
    ST shapeup-sloping or U-shaped
    Classminor abnormality
    Often withtachycardia
    Horizontal ST depression compared with junctional J point depression followed by a rapidly up-sloping ST segment Horizontal (4-1) more specific Up-sloping (4-4) ST-J ↓ ≥ 1 mm, then rises
    Figure 1. Left: horizontal ST depression (code 4-1, more specific for ischaemia). Right: J-point depression ≥ 1 mm with up-sloping ST returning to baseline (Minnesota 4-4).

    Possible causes

    • Sinus tachycardia, exercise, fever, anxiety — the atrial repolarisation wave (Ta) pulls down the J point
    • Myocardial ischaemia, especially if the up-slope is slow and the depression persists 80 ms after J
    • Hypertrophy, medicines, electrolyte disorders

    Clinical significance

    Rapidly up-sloping ST depression at rest is usually of limited significance. A slowly up-sloping depression, especially ≥ 1.5–2 mm measured 80 ms after the J point during an exercise test, may nevertheless indicate ischaemia. A particular pattern that requires urgent attention is the de Winter pattern: up-sloping ST depression in V1–V6 with tall, symmetrical T waves, which can signal acute occlusion of the left anterior descending artery.

    What to do

    Without symptoms, it is usually enough to discuss the ECG at a scheduled visit. The doctor will consider your heart rate at the time of recording and compare it with earlier ECGs.

    Call emergency services

    if you have chest pain, pressure, breathlessness or cold sweat — up-sloping ST depression with tall T waves can accompany an acute heart attack.

    References

    1. Prineas RJ, Crow RS, Zhang ZM. The Minnesota Code Manual of Electrocardiographic Findings. 2nd ed. London: Springer; 2010. doi:10.1007/978-1-84882-778-3
    2. de Winter RJ, Verouden NJW, Wellens HJJ, Wilde AAM. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008;359(19):2071–2073. doi:10.1056/NEJMc0804737
    3. Rautaharju PM, Surawicz B, Gettes LS. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part IV: the ST segment, T and U waves, and the QT interval. Circulation. 2009;119(10):e241–e250. doi:10.1161/CIRCULATIONAHA.108.191096

    This article is for general information and does not replace a consultation with a doctor. ECG findings must be interpreted by a physician together with symptoms and other tests.

    Published on 14 May 2019