Thrombolytic therapy to the patients with de Winter electrocardiographic pattern, is it right?

de Winter syndrome, a STEMI-equivalent ECG pattern leading to life-threatening arrhythmia: A case report from a non-cardiac catheterization laboratory hospital

de Winter syndrome is a rare but important electrocardiographic pattern to recognize in patients presenting with chest pain. Under-recognition and delayed revascularization in patients with de Winter syndrome may lead to poor clinical outcomes. Despite increasing evidence of its association with total occlusion of the left anterior descending artery, the role of thrombolysis in the absence of percutaneous coronary intervention is not specifically addressed in recent international guidelines. Herein, we report a case of a 50-year-old gentleman with no known medical illness who presented with excruciating chest pain associated with diaphoresis, nausea, and reduced effort tolerance. Clinical examination revealed a distressed patient with bibasal crepitations with no other significant findings. The first ECG was sinus bradycardia with poor R-wave progression. ECG repeated 6 h later revealed de Winter syndrome. Within minutes, the patient developed sustained pulse ventricular tachycardia requiring synchronized cardioversion. The patient was intubated for impending cardiorespiratory failure. We took the pharmacoinvasive approach. The patient received thrombolytic therapy as percutaneous coronary intervention (PCI) was not available and transferring to the nearest cardiac center was not possible within the therapeutic window. He was then subsequently transferred to the nearest cardiac center post thrombolysis for PCI. We report this case study to highlight the importance of recognizing this STEMI-equivalent ECG pattern in patients presenting with chest pain, and call for randomized control trials to evaluate the effectiveness of thrombolytic therapy as an alternative emergent reperfusion strategy in de Winter syndrome in non-cardiac centers.

The rare presentation of the de Winter's pattern: Case report and literature review

Although not classified as a ST elevated myocardial infarction (STEMI), the patterns known as equivalents also require prompt recognition and treatment. A 50-year-old male with no pertinent history presented to the emergency department for chest pain that radiated to his left shoulder. An electrocardiogram (EKG) revealed findings consistent with the de Winter's pattern, which were greater than 1 mm upsloping ST depressions at the J point in leads V3-V6 (maximally in leads V3-V5), tall, peaked T waves in leads II, III, and V3-V5, ST elevations in lead aVR, and 1 mm ST elevation in V1 and V2. The physical exam, troponins, and other laboratory investigations were unrevealing. Urgent, diagnostic coronary angiography revealed complete occlusion of the proximal left anterior descending (LAD) artery, which was successfully treated with percutaneous coronary intervention (PCI) and two drug-eluting stents. After the stent placement, arterial blood flow was re-established and the ECG normalized. The patient was started on guideline based treatment and discharged home once medically stable. The de Winter's pattern on electrocardiogram indicates a significant coronary artery disease. This pattern requires urgent intervention, typically percutaneous stent placement.

The de Winter ECG pattern: Distribution and morphology of ST depression

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.

De Winter T-wave Electrocardiogram Pattern Due to Thromboembolic Event: A Rare Phenomenon

De winter pattern on the ECG is associated with occlusion of proximal left anterior descending artery. It is an atypical presentation of acute myocardial infarction due to LAD occlusion. We report a case due to thromboembolic occlusion of LAD after chemical cardioversion. It is imperative for cardiologists and physicians to instantly identify the De Winter pattern on ECG to appropriately triage these patients without delay.

De Winter syndrome and ST-segment elevation myocardial infarction can evolve into one another: Report of two cases

BACKGROUND

The de Winter electrocardiography (ECG) pattern is a sign that implies proximal left anterior descending coronary artery occlusion in patients with chest pain. The previous view was that the de Winter ECG pattern is static.

CASE SUMMARY

A 65-year-old man presented with sudden chest pain at rest associated with diaphoresis for 55 min. The first ECG showed only T-wave inversion in III and aVF leads. Another ECG was performed at the 100^th minute, showing upsloping ST segments depressed with tall and symmetrical T waves in the precordial leads; the J point was raised by 0.1 mV at the aVR lead. The patient was referred to our catheterization laboratory. A third ECG showed ST segment elevation by 0.2 mV in the I and aVL leads. The patient underwent emergency coronary angiography, which revealed complete proximal left anterior descending coronary (LAD) occlusion. The second patient presented with a 1-h history of sudden-onset, severe, substernal crushing chest pain. The first ECG showed ST-segment elevation (0.1–1.7 mV) in I, aVL, and precordial leads. The patient was referred to the catheterization laboratory. On arrival, his symptoms alleviated, and ECG showed that the ST-segments had significantly fallen back. The third ECG showed a typical de Winter pattern. Coronary angiography revealed 99% stenosis of the middle LAD.

CONCLUSION

The de Winter ECG pattern is transient and dynamic, and it reflects proximal or mid-LAD subtotal occlusion rather than total occlusion.

Atypical and delayed de Winter electrocardiograph pattern: A case report

RATIONALE

de Winter electrocardiograph (ECG) pattern signifies proximal left anterior descending coronary artery (LAD) occlusion and extensive anterior myocardial infarction, and it is found in about 2% of patients with proximal LAD occlusion. However, it is often unrecognized by physicians. In this case report, we present a patient with chest pain but showing an atypical and delayed de Winter ECG pattern.

PATIENT CONCERNS

A previously healthy 61-year-old man attended our emergency department with chest pain radiating to the left arm and back for 4 hours, who was without serious cardiovascular risk factors. ECG at emergency department showed no significant changes. High-sensitivity cardiac troponin I (hs-cTnI) was within normal limit.

DIAGNOSIS

At 5 hours after onset, ECG showed significant upsloping ST depression at J point in precordial leads V3 to V6, slight ST elevation in aVR and depression in inferior leads, and hs-cTnI peaked at 2.610 μg/L. The diagnosis of de Winter ECG pattern was confirmed by coronary angiography with an occlusion of the proximal LAD.

INTERVENTIONS

A stent was implanted through percutaneous coronary intervention.

OUTCOMES

The patient's chest pain was relieved without further increase of hs-cTnI. ECG after procedure showed ST segment back to baseline in leads V4 to V6, but persistent ST elevation in V1 to V3 with QS or Q wave.

LESSONS

Timely diagnosis of de Winter ECG pattern is very important, especially the atypical and delayed ECG changes. It should be treated as ST elevation myocardial infarction equivalent and deserves emergent revascularization therapy.