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Guo J, Li Z, Wu Y. ST-Segment Elevation Followed by de Winter Electrocardiogram Pattern in a Patient With Chest Pain. JAMA Intern Med 2023; 183:873-874. [PMID: 37338890 DOI: 10.1001/jamainternmed.2023.1558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
This case report describes a patient in their 40s with no history of cardiovascular disease who presented to the emergency department with chest pain accompanied by sweating.
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Affiliation(s)
- Jincheng Guo
- Division of Cardiology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Zixuan Li
- Division of Cardiology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yongxia Wu
- Division of Cardiology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
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2
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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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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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Wang J, Diao S, Ma B. Dynamic evolvement of the de Winter ECG pattern. Ann Noninvasive Electrocardiol 2021; 26:e12881. [PMID: 34245194 PMCID: PMC8411738 DOI: 10.1111/anec.12881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/25/2021] [Accepted: 06/29/2021] [Indexed: 12/15/2022] Open
Abstract
The de Winter electrocardiograph (ECG) pattern in patients with chest pain is associated with occlusion of the proximal left anterior descending (LAD) artery. These patterns were once considered stable conditions, without dynamic evolution of ECG. Recently, several case reports have indicated that this ECG pattern may evolve into ST‐elevation myocardial infarction (STEMI) or may follow the ECG manifestations of STEMI. However, our case report reveals a dynamic evolution from the de Winter pattern to STEMI and then to a normal ECG pattern.
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Affiliation(s)
- Jian Wang
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou, China
| | - ShuLing Diao
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou, China
| | - Baoxin Ma
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou, China
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Liu CW, Zhang JX, Hu YC, Wang L, Zhang YY, Cong HL. The de Winter electrocardiographic pattern evolves to ST elevation in acute total left main occlusion: A case series. Ann Noninvasive Electrocardiol 2021; 27:e12855. [PMID: 34042244 PMCID: PMC8739620 DOI: 10.1111/anec.12855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/08/2021] [Accepted: 04/15/2021] [Indexed: 12/01/2022] Open
Abstract
The de Winter electrocardiographic (ECG) pattern was characterized by upsloping ST‐segment depressions, tall and positive symmetrical T waves in precordial leads. This rare ECG pattern was recognized as an indication of proximal left anterior descending artery occlusion. Less commonly, this ECG pattern was reported in association with occlusion of other coronary artery segments. We present three cases of the de Winter pattern associated with acute total left main occlusion. This pattern may evolve to ST elevation within hours of presentation. Widespread upsloping ST‐segment depressions from V2–V6, centered on V5 were observed in these patients.
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Affiliation(s)
- Chun-Wei Liu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Jing-Xia Zhang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Yue-Cheng Hu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Le Wang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Ying-Yi Zhang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Hong-Liang Cong
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, 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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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: 3.5] [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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Zhang L, Fan Y, Xu J, Yan J, Ruan Q, Jiang X. De Winter syndrome may be an early electrocardiogram pattern of acute myocardial infarction, two cases report. Ann Noninvasive Electrocardiol 2019; 25:e12729. [PMID: 31760672 PMCID: PMC7358831 DOI: 10.1111/anec.12729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 10/23/2019] [Indexed: 11/29/2022] Open
Abstract
Background De Winter syndrome is an electrocardiogram (ECG) pattern related to acute occlusion of the anterior descending artery. The incidence rate of De Winter syndrome is rare, but still requires much attention from clinicians. Methods Two patients who finnaly diagnosed with De Winter syndrome were included in our study. Results A 55‐year‐old male farmer, who was previously healthy, came to the emergency room due to sudden pain in the precordial area for 6 hours, accompanied with back pain and sweating. The second ECG revealed De Winter syndrome. Emergency coronary angiography was taken, which showed a severe atrioventricular block; diffuse stenosis in the proximal and middle segments of the left anterior descending branch, with 90% stenosis in the severest region. Percutaneous coronary intervention (PCI) of the left anterior descending artery was performed. A 70‐year‐old man with a history of hypertension arrived at the Emergency Department with chest pain for 3 hours. The first ECG was performed, which was contacted with de winter syndrome. The second ECG demonstrated acute anterior Myocardial infarction. Emergency coronary angiography showed approximately 95% stenosis at the junction of the proximal and middle segments. PCI of the proximal and middle segments of the left anterior descending artery was performed. Conclusion De Winter syndrome is a type of acute coronary syndrome, which may be an early ECG pattern in the development of acute ST‐segment elevation myocardial infarction. Therefore, once De Winter syndrome is observed on the ECG, acute coronary syndrome, especially acute anterior descending occlusion should not be ignored.
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Affiliation(s)
- Lingzhi Zhang
- Department of Electrocardiogram, The First People's Hospital of Wenling, Wenling, China
| | - Yuncao Fan
- Department of Cardiology, The first people's Hospital of Wenling, Wenling, China
| | - Jinzhong Xu
- Department of Clinical pharmacy, The first people's Hospital of Wenling, Wenling, China
| | - Jianxin Yan
- Department of Clinical laboratory, The First People's Hospital of Wenling, Wenling, China
| | - Qianzi Ruan
- Department of bone and Joint surgery, The First People's Hospital of Wenling, Wenling, China
| | - Xiaoyan Jiang
- Department of Electrocardiogram, The First People's Hospital of Wenling, Wenling, China
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Xu WW, Lu L, Jin MJ. de Winter Electrocardiogram Pattern-An Unusual ST-Segment Elevation Myocardial Infarction Equivalent Pattern. JAMA Intern Med 2019; 179:1575-1577. [PMID: 31524932 DOI: 10.1001/jamainternmed.2019.4127] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Wei-Wei Xu
- Department of Cardiology, Affiliated Dongyang People's Hospital of Wenzhou Medical University, Dongyang, Zhejiang Province, People's Republic of China
| | - Liang Lu
- Department of Cardiology, Affiliated Dongyang People's Hospital of Wenzhou Medical University, Dongyang, Zhejiang Province, People's Republic of China
| | - Mei-Juan Jin
- Department of Cardiology, Affiliated Dongyang People's Hospital of Wenzhou Medical University, Dongyang, Zhejiang Province, People's Republic of China
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Lin YY, Wen YD, Wu GL, Xu XD. De Winter syndrome and ST-segment elevation myocardial infarction can evolve into one another: Report of two cases. World J Clin Cases 2019; 7:3296-3302. [PMID: 31667182 PMCID: PMC6819298 DOI: 10.12998/wjcc.v7.i20.3296] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 09/19/2019] [Accepted: 09/25/2019] [Indexed: 02/05/2023] Open
Abstract
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 100th 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.
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Affiliation(s)
- Yang-Yi Lin
- Department of Cardiology, Jiading District Central Hospital Affiliated Shanghai University of Medical and Health Sciences, Shanghai 201800, China
| | - Yu-Dan Wen
- Department of Electrocardiology, the Third Affiliated Hospital of Wenzhou Medical University, Wenzhou 325200, Zhejiang Province, China
| | - Guo-Lin Wu
- Department of Cardiology, Jiading District Central Hospital Affiliated Shanghai University of Medical and Health Sciences, Shanghai 201800, China
| | - Xiang-Dong Xu
- Department of Cardiology, Jiading District Central Hospital Affiliated Shanghai University of Medical and Health Sciences, Shanghai 201800, China
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Xu W, Xu L, Peng J, Huang S. Thrombolytic therapy in a patient with chest pain with de Winter ECG pattern occurred after ST-segment elevation: A case report. J Electrocardiol 2019; 56:4-6. [DOI: 10.1016/j.jelectrocard.2019.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/09/2019] [Accepted: 06/12/2019] [Indexed: 12/28/2022]
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