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Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 48-50

de winter sign: A masquerading electrocardiogram in ST-elevation myocardial infarction

Department of Cardiology, Government Medical College, Kozhikode, Kerala, India

Date of Web Publication8-Mar-2017

Correspondence Address:
Dr. Kailash Kumar Goyal
Department of Cardiology, Government Medical College, Kozhikode - 673 008, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/heartindia.heartindia_49_16

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Electrocardiogram (ECG) is usually the first and most important test in patients with acute coronary syndrome which helps to diagnose as well as classify patients into ST elevation or non-ST elevation myocardial infarction (STEMI). This classification is important as both the groups differ in their pathophysiology as well as management. Patients with STEMI require urgent reperfusion therapy either with percutaneous coronary intervention or fibrinolysis, if the earlier is not available. They may, however, sometimes present without obvious ST elevation in ECG resulting in delayed diagnosis and reperfusion therapy. Identification of such STEMI equivalents, therefore, becomes very important for physicians as well as interventional cardiologists. We report a 62-year-old male who presented without an obvious ST elevation in ECG and subsequently found to be having acute obstruction of mid-left anterior descending artery.

Keywords: de Winter sign, fibrinolysis, percutaneous coronary intervention, ST elevation myocardial infarction

How to cite this article:
Goyal KK, Rajasekharan S, Muneer K, Sajeev CG. de winter sign: A masquerading electrocardiogram in ST-elevation myocardial infarction. Heart India 2017;5:48-50

How to cite this URL:
Goyal KK, Rajasekharan S, Muneer K, Sajeev CG. de winter sign: A masquerading electrocardiogram in ST-elevation myocardial infarction. Heart India [serial online] 2017 [cited 2023 May 28];5:48-50. Available from: https://www.heartindia.net/text.asp?2017/5/1/48/201748

  Introduction Top

Morbidity and mortality associated with ST-elevation myocardial infarction (STEMI) has been dramatically reduced after the introduction of reperfusion therapy either with fibrinolysis or percutaneous coronary intervention (PCI). Hence, early identification of these patients and timely intervention is the gold standard management for STEMI. A small group of patients may, however, present with ST-T changes which are not typical of STEMI and failure to identify such patients may lead to delay in diagnosis and reperfusion therapy with catastrophic results. We herein present a case of acute left anterior descending (LAD) artery occlusion presenting with electrocardiographic (ECG) features mimicking non-ST elevation acute coronary syndrome.

  Case Report Top

A 62-year-old male presented with retrosternal pain radiating to left arm for 8 h. He was a chronic smoker and hypertensive on irregular treatment. He was hemodynamically stable with a blood pressure of 130/80 mmHg and a regular pulse rate of 62/min. Admission ECG [Figure 1] showed a 3–5 mm upsloping ST segment depression in leads V2–V6 at the J point which continued into tall, positive symmetrical T-waves. There were ST depressions in leads I and II. Further, lead aVR showed a 2 mm ST elevation. The QRS complex was not widened. Troponin I was significantly positive. Patient was taken immediately for a primary PCI. Coronary angiography showed a tight thrombus filled lesion in mid-LAD artery [Figure 2]. Successful coronary angioplasty was done using a second-generation drug-eluting stent, and final injection showed a thrombolysis in myocardial infarction Grade 3 flow [Figure 3]. Postprocedure ECG showed resolution of ST-T changes. Patient was discharged on the 3rd postoperative day with a predischarge echocardiogram showing mild hypokinesia of LAD territory with good left ventricular function.
Figure 1: Electrocardiogram of the patient showing de Winter ST T complex in leads V2–V6

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Figure 2: Coronary angiogram showing lesion in mid-left anterior descending

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Figure 3: Coronary angiogram postpercutaneous transluminal coronary angioplasty showing thrombolysis in myocardial infarction Grade 3 flow

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  Discussion Top

The de Winter pattern on ECG was first recognized and reported by de Winter et al. in 2008.[1] They found this pattern in about 2% (30 of 1532) of patients with proximal LAD occlusion. These findings were later replicated by Verouden et al.[2] in 2009, he noticed a similar pattern in 35 of 1890 patients presenting with acute LAD occlusion. It was observed that patients with this ECG pattern were relatively young, predominantly male and had a higher incidence of dyslipidemia compared to patients with LAD occlusion and classical STEMI on ECG. de Winter pattern was recognized as a STEMI equivalent by Rokos et al. in 2010[3] as most of the cases were associated with acute LAD occlusion and required emergent reperfusion therapy with fibrinolysis or a primary PCI. However, the 2013 American College of Cardiology Foundation/American Heart Association updated guidelines for the diagnosis and management of STEMI do not recommend fibrinolysis in such cases.[4]

The de Winter pattern should not be confused with hyperacute T-waves or Wellens' pattern on ECG. Hyperacute T-waves occur within minutes of coronary artery occlusion and progress rapidly to classical STEMI pattern. Patients with Wellens' syndrome have biphasic or inverted T-waves in leads V1 to V3 and represent critical stenosis of LAD which can develop extensive anterior wall infarction within days.

The definite electrophysiologic mechanism responsible for this ECG pattern is not known. Verouden et al.[2] postulated that area of transmural ischemia was very large in these patients so that no injury currents were generated toward the precordial leads but only upward toward lead aVR. This, however, could not explain the presence of this pattern being limited to only 2% of patients with proximal LAD occlusion. de Winter et al.[1] mentioned that an anatomical variant of Purkinje fibers with an endocardial conduction delay may be responsible for the ECG changes. They also hypothesized that the absence of ST elevation could be related to lack of activation of sarcolemmal ATP-sensitive potassium channels (KATP) by ischemic ATP depletion as shown in KATP knock-out animal models of acute ischemia.[5]

Irrespective of the mechanism, significance of this pattern lies in that failure to recognize these ECG changes may often lead to undertreatment.[6] Hence, it is imperative for physicians involved in the triage of patients as well as cardiologists to be familiar with this ECG pattern and treat them as an acute LAD occlusion.

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Conflicts of interest

There are no conflicts of interest.

  References Top

de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA; Interventional Cardiology Group of the Academic Medical Center. A new ECG sign of proximal LAD occlusion. N Engl J Med 2008;359:2071-3.  Back to cited text no. 1
Verouden NJ, Koch KT, Peters RJ, Henriques JP, Baan J, van der Schaaf RJ, et al. Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion. Heart 2009;95:1701-6.  Back to cited text no. 2
Rokos IC, French WJ, Mattu A, Nichol G, Farkouh ME, Reiffel J, et al. Appropriate cardiac cath lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction. Am Heart J 2010;160:995-1003.  Back to cited text no. 3
O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr., Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362-425.  Back to cited text no. 4
Li RA, Leppo M, Miki T, Seino S, Marbán E. Molecular basis of electrocardiographic ST-segment elevation. Circ Res 2000;87:837-9.  Back to cited text no. 5
Goebel M, Bledsoe J, Orford JL, Mattu A, Brady WJ. A new ST-segment elevation myocardial infarction equivalent pattern? Prominent T-wave and J-point depression in the precordial leads associated with ST-segment elevation in lead aVr. Am J Emerg Med 2014;32:287.e5-8.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3]


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