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Felicioni SP, de Alencar JN, Centemero MP, Lourenço UR, De Marchi MFN, Scheffer MK, Costa ACM, Fernandes RC, Uemoto VR, Baronetti R. The de Winter electrocardiographic pattern: A systematic review of case reports. J Electrocardiol 2024; 87:153821. [PMID: 39514930 DOI: 10.1016/j.jelectrocard.2024.153821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2024] [Revised: 10/26/2024] [Accepted: 10/29/2024] [Indexed: 11/16/2024]
Abstract
BACKGROUND It has been established that concurrent ST-T alterations in limb leads can assist in identifying the location of left anterior descending (LAD) artery occlusion. The de Winter pattern is an atypical electrocardiographic manifestation characterized by ST-segment depression associated with LAD artery occlusion. We hypothesized that this atypical pattern could potentially interfere with the accurate localization of the LAD occlusion site on the electrocardiogram. We aimed to describe the distinctive characteristics of the de Winter pattern and to compare electrocardiographic variables in proximal and distal occlusions of the LAD artery. METHODS A systematic review was conducted using the PRISMA guidelines. PubMed, Scopus, and Web of Science were searched from their inception to June 2024. Continuous variables were compared using the Kruskal-Wallis test. RESULTS Sixty-six cases with LAD related lesions were included. The majority of cases involved young males with a low proportion of prior coronary artery disease. Most patients had sinus rhythm and normal QRS duration. ST-T changes in limb leads were common in the patients studied (91%), but our analysis showed that differentiating between proximal and distal occlusions based on these changes was challenging. CONCLUSION The de Winter pattern is primarily observed in young males with a low proportion of prior coronary artery disease. While ST-T changes in limb leads are frequent, localizing the LAD occlusion site based on these changes can be difficult. Further research is needed to understand the underlying mechanisms, prevalence, and improve diagnostic accuracy for this atypical pattern.
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Affiliation(s)
- Sandro Pinelli Felicioni
- Departamento de Tele-Eletrocardiografia, Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil.
| | - José Nunes de Alencar
- Departamento de Tele-Eletrocardiografia, Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil
| | | | | | | | - Matheus Kiszka Scheffer
- Departamento de Tele-Eletrocardiografia, Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil
| | - Ana Carolina Muniz Costa
- Departamento de Tele-Eletrocardiografia, Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil
| | - Rinaldo Carvalho Fernandes
- Departamento de Tele-Eletrocardiografia, Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil
| | - Vinicius Ruiz Uemoto
- Divisão de Bioengenharia, Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil
| | - Ramon Baronetti
- Divisão de Bioengenharia, Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil
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Alhatemi AQM, Hashim HT, Aziz EMH, Abdulhussain TK, Hashim AT. De Winter syndrome in action: Captured on defibrillator. Clin Case Rep 2024; 12:e8511. [PMID: 38333658 PMCID: PMC10849977 DOI: 10.1002/ccr3.8511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/10/2024] Open
Abstract
De Winter syndrome, though rare, demands heightened clinical suspicion. Recognizing its electrocardiographic subtleties is crucial, as prompt diagnosis allows for life-saving interventions such as percutaneous coronary intervention or thrombolysis.
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Jayaprasad N. De Winter electrocardiographic pattern in a young patient with acute myocardial infarction. Proc AMIA Symp 2023; 36:219-221. [PMID: 36876265 PMCID: PMC9980674 DOI: 10.1080/08998280.2023.2165022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
A significant number of patients with acute coronary occlusion present with atypical electrocardiographic features in the emergency department. The de Winter pattern is suggestive of proximal left anterior descending coronary artery occlusion. Timely identification and immediate reperfusion is of utmost importance in these cases. The electrocardiographic pattern and its evolution in a young patient with acute myocardial infarction is described here.
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Balta A, Ceasovschih A, Șorodoc V, Dimitriadis K, Güzel S, Lionte C, Stătescu C, Sascău RA, Mantzouranis E, Sakalidis A, Vlachakis PK, Tsioufis P, Kordalis A, Tsiamis E, Tsioufis K, Șorodoc L. Broad Electrocardiogram Syndromes Spectrum: From Common Emergencies to Particular Electrical Heart Disorders. J Pers Med 2022; 12:jpm12111754. [PMID: 36573711 PMCID: PMC9697753 DOI: 10.3390/jpm12111754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/13/2022] [Accepted: 10/19/2022] [Indexed: 12/30/2022] Open
Abstract
Electrocardiogram (ECG) still remains a very useful diagnostic method in modern cardiology. Its broad availability, noninvasiveness and good sensitivity explain why it plays a capital role in the very beginning of the process of diagnosis for every patient, with or without cardiac-related complaints. For the practitioner, good training in ECG interpretation is mandatory. Sometimes, the ECG trace reveals particular aspects that may cause confusion and complicate decision-making. In this article, we present several less common situations underlying the general context and ECG features. The syndromes studied have a high pathological significance and may range from acute emergencies that call for a rapid therapeutical response to chronic syndromes that require prolonged observation, monitoring and risk stratification.
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Affiliation(s)
- Anastasia Balta
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iasi, Romania
| | - Alexandr Ceasovschih
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iasi, Romania
- Correspondence: (A.C.); (V.Ș.); (K.D.)
| | - Victorița Șorodoc
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
- Correspondence: (A.C.); (V.Ș.); (K.D.)
| | - Kyriakos Dimitriadis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
- Correspondence: (A.C.); (V.Ș.); (K.D.)
| | - Sara Güzel
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iasi, Romania
| | - Cătălina Lionte
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iasi, Romania
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Cristian Stătescu
- Cardiology Department, Cardiovascular Diseases Institute, 700503 Iasi, Romania
| | - Radu Andy Sascău
- Cardiology Department, Cardiovascular Diseases Institute, 700503 Iasi, Romania
| | - Emmanouil Mantzouranis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Athanasios Sakalidis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Panayotis K. Vlachakis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Panagiotis Tsioufis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Athanasios Kordalis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Eleftherios Tsiamis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Konstantinos Tsioufis
- 1st Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 11527 Athens, Greece
| | - Laurențiu Șorodoc
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T. Popa, 700115 Iasi, Romania
- 2nd Internal Medicine Department, Sf. Spiridon Clinical Emergency Hospital, 700111 Iasi, Romania
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ERDEM AB, TÜMER M. De Winter Wave with ST Segment Elevation Equivalent with Speech Disorder; A Case Report. JOURNAL OF EMERGENCY MEDICINE CASE REPORTS 2022. [DOI: 10.33706/jemcr.991552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Wang S, Shen L. de Winter syndrome or inferior STEMI? BMC Cardiovasc Disord 2021; 21:614. [PMID: 34961517 PMCID: PMC8713409 DOI: 10.1186/s12872-021-02441-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background The de Winter electrocardiography (ECG) pattern is associated with acute total or subtotal occlusion of the left anterior descending coronary artery (LAD) characterized by upsloping ST-segment depression at the J point in leads V1–V6 without ST-segment elevation. Case presentation We report an atypical style case of the de Winter ECG pattern accompanied by ST elevation in inferior leads. The patient underwent emergency coronary angiography, which revealed total occlusion of the proximal LAD with no observable stenosis in the right coronary artery. Conclusion ECG-related changes in acute total LAD occlusion can present with the de Winter pattern and ST elevation in inferior leads. Recognizing this atypical ECG pattern is critical for immediate reperfusion therapy.
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Affiliation(s)
- Shijun Wang
- Department of Cardiology, Affiliated Hospital of Jiaxing University, No.1882 Zhonghuan South Road, Jiaxing, 314000, Zhejiang, People's Republic of China
| | - Liang Shen
- Department of Cardiology, Affiliated Hospital of Jiaxing University, No.1882 Zhonghuan South Road, Jiaxing, 314000, Zhejiang, People's Republic of China.
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Huang W, Mai L, Lu J, Li W, Huang Y, Hu Y. Evolutionary de Winter pattern: from STEMI to de Winter ECG-a case report. ESC Heart Fail 2021; 9:771-774. [PMID: 34850595 PMCID: PMC8788021 DOI: 10.1002/ehf2.13711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/12/2021] [Accepted: 11/01/2021] [Indexed: 12/26/2022] Open
Abstract
The de Winter electrocardiography (ECG) pattern is a sign that implies proximal left anterior descending coronary artery occlusion in patients with chest pain. We report a case of a 34-year-old man with a history of smoking who presented to the local emergency department with a 49 min history of chest pain. The first ECG of the patient indicated that ST-segment elevation was noted in the lead V2-V4; 57 min later, a second ECG revealed a typical de Winter syndrome when the patient was transferred to the emergency chest pain centre of our hospital. A percutaneous coronary intervention (PCI) was performed approximately 8 h later because the patient initially refused the PCI. Acute coronary artery angiography showed that the proximal left anterior descending coronary artery was completely occluded. Our case suggests that ST-segment elevation myocardial infarction may evolve in the direction of de Winter, which reflects a coronary thrombus in formation, so the de Winter ECG pattern should not be considered static.
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Affiliation(s)
- Weijun Huang
- Department of Cardiology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), Shunde, Foshan, China
| | - Linlin Mai
- Department of Cardiology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), Shunde, Foshan, China
| | - Jianhua Lu
- Department of Cardiology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), Shunde, Foshan, China
| | - Wenshen Li
- Department of Cardiology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), Shunde, Foshan, China
| | - Yuli Huang
- Department of Cardiology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), Shunde, Foshan, China
| | - Yunzhao Hu
- Department of Cardiology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), Shunde, Foshan, China
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Ramakumar V, Panda A, Yadav S. A Rare Sequence of Events in Acute Coronary Syndrome. JAMA Intern Med 2021; 181:1391-1392. [PMID: 34424261 DOI: 10.1001/jamainternmed.2021.4016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Asharam Panda
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Satyavir Yadav
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
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Singh A, Dwivedi S, Pradhan A, Narain VS, Sethi R, Chandra S, Vishwakarma P, Chaudhary G, Bhandari M, Sharma A. Isolated ST-Elevation Myocardial Infarction Involving Leads I and aVL: Angiographic and Electrocardiographic Correlations from a Tertiary Care Center. Cardiol Res Pract 2021; 2021:7638020. [PMID: 34239726 PMCID: PMC8241503 DOI: 10.1155/2021/7638020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 02/12/2021] [Accepted: 06/06/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Determining the infarct-related artery in STEMI during a coronary angiogram can be challenging due to the affliction of multiple vessels. Isolated STEMI involving only EKG leads I and aVL is infrequent. Localization of infarct-related artery based on EKG findings has not been previously done in this subset. METHODS All consecutive de novo acute coronary syndrome (ACS) patients admitted to coronary care unit with ST elevations involving only leads I and aVL were screened for enrollment. Patients with ST elevation in any additional lead and those who refused a coronary angiogram were excluded. Subsequently, a coronary angiogram was done as part of primary PCI or a pharmacoinvasive approach to identify the infract-related artery (IRA). IRA was defined by characteristics of lesion, flow of blood through stenosis, and presence of intracoronary thrombus. Coronary angiogram was interpreted by two independent observers blinded to the EKG findings. ST changes in inferior and precordial leads were analyzed to find ECG predictors of the culprit artery. RESULTS A total of 54 eligible patients of ACS were included in the study. The first major diagonal (D1) was the most frequent IRA in 35.2% followed by left circumflex-obtuse marginal (LCX-OM11) in 29.6%, left anterior descending (LAD) in 20.4%, and ramus intermedius (RI) in 14.8%. Out of total patients with ST depression in lead V2, the LCX-OM11 group was IRA in 50% cases while the RI, D1, and LAD groups accounted for 31.8%, 13.6%, and 4.5%, respectively (p < 0.001). Similarly, LCX-OM1 was the most frequent IRA subjects with ST depressions in leads V1 and V3 (44.4%; p = 0.010 and 46.2%; p = 0.003, resp.). On the contrary, in patients with ST depression in lead III, LAD and D1 were the most frequent IRA as compared to LCX-OM1 and RI though statistical significance was not attained (p = 0.857 for lead III). ST-segment depression in lead V2 had a positive predictive value of 60% and a negative predictive value of 100% for LCX-OM1 as IRA. Similarly, ST-segment depression in lead V2 had a positive predictive value of 20% and a negative predictive value of 100% for the RI group. CONCLUSIONS In patients presenting with isolated ST elevation in leads I and aVL, the most frequent IRA on angiogram was first diagonal. ST depressions in EKG leads V1-V3 were the most common predictor of LCX-OM1 while those in inferior leads indicated LAD-D1 as the IRA.
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Affiliation(s)
- Abhishek Singh
- Department of Medicine, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Sudhanshu Dwivedi
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Varun S Narain
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Rishi Sethi
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Sharad Chandra
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Pravesh Vishwakarma
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Gaurav Chaudhary
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Monika Bhandari
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Akhil Sharma
- Department of Cardiology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
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Wu HY, Cheng G, Cao YW. Chest pain showing precordial ST-segment elevation in a 96-year-old woman with right coronary artery occlusion: A case report. World J Clin Cases 2021; 9:1877-1884. [PMID: 33748237 PMCID: PMC7953383 DOI: 10.12998/wjcc.v9.i8.1877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/23/2020] [Accepted: 01/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Typically, right coronary artery (RCA) occlusion causes ST-segment elevation in inferior leads. However, it is rarely observed that RCA occlusion causes ST-segment elevation only in precordial leads. In general, an electrocardiogram is considered to be the most important method for determining the infarct-related artery, and recognizing this is helpful for timely discrimination of the culprit artery for reperfusion therapy. In this case, an elderly woman presented with chest pain showing dynamic changes in precordial ST-segment elevation with RCA occlusion.
CASE SUMMARY A 96-year-old woman presented with acute chest pain showing precordial ST-segment elevation with dynamic changes. Myocardial injury markers became positive. Coronary angiography indicated acute total occlusion of the proximal nondominant RCA, mild atherosclerosis of left anterior descending artery and 75% stenosis in the left circumflex coronary artery. Percutaneous coronary intervention was conducted for the RCA. Repeated manual thrombus aspiration was performed, and fresh thrombus was aspirated. A 2 mm × 15 mm balloon was used to dilate the RCA with an acceptable angiographic result. The patient’s chest pain was relieved immediately. A postprocedural electrocardiogram showed alleviation of precordial ST-segment elevation. The diagnosis of acute isolated right ventricular infarction caused by proximal nondominant RCA occlusion was confirmed. Echocardiography indicated normal motion of the left ventricular anterior wall and interventricular septum (ejection fraction of 54%), and the right ventricle was slightly dilated. The patient was asymptomatic during the 9-mo follow-up period.
CONCLUSION Cardiologists should be conscious that precordial ST-segment elevation may be caused by occlusion of the nondominant RCA.
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Affiliation(s)
- Hao-Yu Wu
- Department of Cardiology, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
| | - Gong Cheng
- Department of Cardiology, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
| | - Yi-Wei Cao
- Department of Electrocardiology, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
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Affiliation(s)
- Yi-Wei Cao
- Department of Electrocardiology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi Province, People's Republic of China
| | - Hao-Yu Wu
- Department of Cardiology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi Province, People's Republic of China
| | - Lei Liang
- Department of Cardiology, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi Province, People's Republic of China
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John TJ, Pecoraro A, Weich H, Joubert L, Griffiths B, Herbst P. The de Winter's pattern revisited: a case series. Eur Heart J Case Rep 2020; 4:1-5. [PMID: 33442615 PMCID: PMC7793130 DOI: 10.1093/ehjcr/ytaa402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/15/2020] [Accepted: 10/01/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND The de Winter's electrocardiogram (ECG) pattern signifying proximal left anterior descending (LAD) artery occlusion was first described in 2008. The ECG changes were thought to be static and mechanisms for this were suggested. In addition, the optimal management of these patients was reported to be via a primary percutaneous coronary intervention (PCI) strategy. CASE SUMMARY Case 1: A 48-year-old gentleman presented with a 2-h history of ischaemic chest pain with initial de Winter's pattern on ECG. This progressed to anterior ST-elevation myocardial infarction (STEMI) complicated by ventricular fibrillation. Emergency angiography revealed a mid-vessel LAD occlusion which was successfully reperfused. Case 2: A 34-year-old female presented with a 2-h history of ischaemic chest pain with initial ECG showing a de Winter's pattern. Due to concerns of performing PCI timeously, a pharmacoinvasive strategy of reperfusion was adopted with resolution of the de Winter's pattern. Urgent angiography revealed a proximal LAD lesion which was successfully stented. DISCUSSION The two cases highlight that the de Winter's pattern may in fact not be static, but rather lie along the continuum of ischaemia and may evolve into STEMI. In addition, we provide further evidence that if primary PCI cannot be offered in a timeous manner, thrombolytic therapy may be considered in such patients. The de Winter's pattern remains a high-risk ECG pattern that requires early recognition and intervention.
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Affiliation(s)
- Thadathilankal-Jess John
- Division of Cardiology, Department of Medicine Stellenbosch University & Tygerberg Academic Hospital PO Box 241, Cape Town 8000, South Africa
| | - Alfonso Pecoraro
- Division of Cardiology, Department of Medicine Stellenbosch University & Tygerberg Academic Hospital PO Box 241, Cape Town 8000, South Africa
| | - Hellmuth Weich
- Division of Cardiology, Department of Medicine Stellenbosch University & Tygerberg Academic Hospital PO Box 241, Cape Town 8000, South Africa
| | - Lloyd Joubert
- Division of Cardiology, Department of Medicine Stellenbosch University & Tygerberg Academic Hospital PO Box 241, Cape Town 8000, South Africa
| | - Bradley Griffiths
- Division of Cardiology, Department of Medicine Stellenbosch University & Tygerberg Academic Hospital PO Box 241, Cape Town 8000, South Africa
| | - Philip Herbst
- Division of Cardiology, Department of Medicine Stellenbosch University & Tygerberg Academic Hospital PO Box 241, Cape Town 8000, South Africa
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Zhan ZQ, Li Y, Han LH, Nikus KC, Birnbaum Y, Baranchuk A. The de Winter ECG pattern: Distribution and morphology of ST depression. Ann Noninvasive Electrocardiol 2020; 25:e12783. [PMID: 32588536 PMCID: PMC7507532 DOI: 10.1111/anec.12783] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/16/2020] [Accepted: 06/01/2020] [Indexed: 12/19/2022] Open
Abstract
Background The reported positive predictive value (PPV) for the “de Winter ECG pattern” to predict an acute left anterior descending artery (LAD) lesion is inconsistent. Besides, the morphology of upsloping or nonupsloping ST depression (STD) may have different significance of severity and prognostication. Methods We searched the MEDLINE database using “de Winter” or “junctional ST‐depression with tall symmetrical T‐waves” or “tall T wave” or “STEMI equivalent” as the item up to March 2020. We compared the ECG differences between the different culprit arteries and various morphological STD. Results A total of 70 patients with analyzable ECGs were included. In 60 patients (LAD group), the LAD was the culprit artery, while in 10 patients (non‐LAD group), there were other etiologies. Maximal STD in V2 or V3 had a PPV of 89% of all patients and 98% of patients without ST elevation in V2 to detect an acute LAD lesion. The presence of q/Q‐wave or poor R‐wave progression in the precordial leads was significantly more often found in patients with upsloping STD than in patients with nonupsloping STD in the LAD group (84% vs. 27%, p < .01). In 18 patients, the ECG showed a change from upsloping to nonupsloping STD from the leads with maximal STD to the surrounding leads with less STD. Conclusions The location of the maximal STD in the precordial leads differs between patients with LAD as the culprit artery and other etiologies of the de Winter ECG pattern. Upsloping STD signifies more severe signs of ischemia than nonupsloping STD.
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Affiliation(s)
- Zhong-Qun Zhan
- Department of Cardiology, Shenzhen Hospital-University of Chinese Academy of Sciences, Shenzhen, China
| | - Yang Li
- Department of Cardiology, Shenzhen Hospital-University of Chinese Academy of Sciences, Shenzhen, China
| | - Li-Hong Han
- Department of Cardiology, Shenzhen Hospital-University of Chinese Academy of Sciences, Shenzhen, China
| | - Kjell C Nikus
- Department of Cardiology, Heart Center, Tampere University Hospital, Tampere and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Yochai Birnbaum
- The Section of Cardiology, Baylor College of Medicine and Texas Heart Institute, Baylor St. Luke Medical Center, Houston, TX, USA
| | - Adrian Baranchuk
- Department of Cardiology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
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