de Winter sign–A STEMI Equivalent

Dear Editor,

A 63-years-old male with a history of heavy smoking presented to us with severe retrosternal chest pain of 1 h duration. The patient was hemodynamically stable. The 12-lead ECG obtained at admission showed ST-segment depression (1 mm) at the J-point, with tall, symmetrical T-waves in the precordial leads along with ST-segment elevation (0.5–1 mm) in the lead avR (Fig. 1). These findings suggested electrocardiographic de Winter sign. This sign is a marker of acute occlusion of the left anterior descending (LAD) coronary artery and is helpful in diagnosing anterior wall ST elevation myocardial infarction (STEMI) even in the absence of ST-segment elevation in the precordial leads.¹ Fortunately, we were able to recognise this entity timely and subjected the patient to emergency primary percutaneous coronary intervention (PCI). On coronary angiography, there was total thrombotic occlusion of the LAD after the first diagonal (Fig. 2, Fig. 3). Left circumflex coronary artery was also diseased significantly at its ostium and distal part. Right coronary artery was normal. PCI of the culprit artery was performed and a 3.0 × 23 mm everolimus-eluting stent was successfully deployed. TIMI-3 flow was achieved through and beyond the stent and there was no residual stenosis (Fig. 4). The post PCI ECG returned to normal (Fig. 5). Echocardiogram revealed no wall motion abnormality and a normal ventricular function. The patient remained asymptomatic post PCI and was discharged 2 days later.

Fig. 1.

Presentation electrocardiogram showing ST-segment depression (1 mm) at the J-point, with tall, symmetrical T-waves in the precordial leads along with ST-segment elevation (0.5-1 mm) in the lead avR.

Fig. 2.

Coronary angiogram-LAO Caudal view, showing total occlusion of LAD after first diagonal.

Fig. 3.

Coronary angiogram showing thrombotic occlusion of the mid LAD.

Fig. 4.

Post PCI electrocardiogram, showing resolution of earlier changes.

Fig. 5.

Post stent deployment angiogram, showing no residual stenosis.

This case highlights the need to identify certain subtle ECG patterns in which urgent coronary angiography and intervention may improve patient outcomes. The de Winter sign is one such pattern, first described in 2008, and is seen in around 2% of patients with acute occlusion of LAD coronary artery.¹ Therefore, these patients qualify for immediate reperfusion therapy, preferably with primary PCI. The electrophysiological cause of this pattern remains uncertain. It is hypothesised that this pattern may be related to a mutation of sarcolemmal potassium- ATP channels, preventing the occurrence of ST elevation at any time.²

The de Winter changes appear different than hyperacute T-waves of STEMI.³ Characteristics of the latter include tall T-waves in the precordial leads with/without symmetrical shapes, and accompanied by a wide base. Importantly they are transient changes dynamically progressing into overt ST-segment elevation in the precordial leads. On the contrary, de Winter ECG pattern has often been observed as a static pattern (ie, lack of evolution to STEMI) despite the total occlusion of LAD coronary artery.³ It is important for the physicians to be aware of this STEMI equivalent pattern to ensure appropriate and urgent reperfusion therapy.

Source of support in the form of grants, equipments, drugs

None.

Conflicts of interest of each author/contributor

None.

Criteria for inclusion in the authors’ list

KM, AB and AG made the diagnosis. KM wrote the manuscript. AB gave conceptual advice. Final manuscript has been read and approved by all the authors, and each author states that the manuscript represents honest work.