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Zheng XB. Dressler - de Winter sign with acute inferoposterior STEMI: An ECG dilemma in artery localization. J Electrocardiol 2024; 86:153769. [PMID: 39126969 DOI: 10.1016/j.jelectrocard.2024.153769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/20/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024]
Abstract
The Dressler-de Winter sign is an electrocardiogram (ECG) pattern characterized by upsloping ST-segment depression in leads V1-V6 followed by tall, hyperacute T waves, typically indicating an occlusion of the left anterior descending artery (LAD). We present a case involving an inferoposterior ST-segment elevation myocardial infarction (STEMI) with a variant of the de Winter sign, a concept of ST-segment continuum in the precordial leads. Despite initial ECG findings suggesting right coronary artery (RCA) or left circumflex artery (LCX) involvement, coronary angiography confirmed occlusion of the wrap-around LAD distal to the first septal (S1) and diagonal branch (D1) and revealed a left dominant system accompanied by a small non-dominant RCA. This case highlights the diagnostic complexity in accurately localizing the culprit artery in STEMI cases exhibiting the de Winter sign. Understanding such ECG variants is crucial for analyzing the mechanisms of acute ischemia and ensuring accurate assessment of the culprit vessel for effective revascularization.
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Affiliation(s)
- Xiao-Bin Zheng
- Shanxi Cardiovascular Hospital, Department of Cardiology, Taiyuan 030000, China.
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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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Wang J, Li J, Diao S, Xu H, Ding F. Atypical de Winter ECG pattern may be the mirror image of ST elevation. Ann Noninvasive Electrocardiol 2021; 27:e12915. [PMID: 34808022 PMCID: PMC9107089 DOI: 10.1111/anec.12915] [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: 09/21/2021] [Revised: 10/20/2021] [Accepted: 11/01/2021] [Indexed: 12/16/2022] Open
Abstract
Background: The de Winter ECG pattern of ST‐segment depression and tall symmetrical T waves, known as an ST elevation equivalent, accounts for approximately 2% of patients with occlusion of the proximal left anterior descending (LAD) coronary artery. The classic de Winter pattern is restricted to cases without ST elevation. However, mixed cases with different types of ST deviation have been described. Here, we describe an interesting case as an example of an ST elevation myocardial infarction (STEMI) equivalent, showing transient transmural ischemia of the inferolateral myocardium, with ECG changes that mimic the de Winter pattern.
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Affiliation(s)
- Jian Wang
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou, China
| | - Jingsen Li
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou, China
| | - Shuling Diao
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou, China
| | - Huipu Xu
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou, China
| | - Faming Ding
- Department of Cardiology, Binzhou Medical University Hospital, Binzhou, China
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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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Zhan ZQ, Li Y, Wu LH, Han LH. A de Winter electrocardiographic pattern caused by left main coronary artery occlusion: A case report. J Int Med Res 2021; 48:300060520927209. [PMID: 32475184 PMCID: PMC7263117 DOI: 10.1177/0300060520927209] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
A de Winter electrocardiographic (ECG) pattern comprising precordial junctional ST depression followed by tall, positive symmetrical T waves in leads V1/V2 to V4/V6 is often concomitant with ST elevation in lead aVR. This finding strongly suggests proximal left anterior descending coronary artery occlusion. We described a patient who had the de Winter ECG pattern in leads V2 to V4 by acute left main coronary artery (LMCA) occlusion. The ECG also showed maximal ST depression in leads V4 to V5 and inverted T waves in leads V5 to V6. This finding indicated a global subendocardial ischemia ECG pattern, which suggested LMCA or three-vessel disease. Early recognition of this ECG manifestation is important for averting a disastrous prognosis in acute LMCA occlusion because emergent coronary intervention may be life-saving.
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Affiliation(s)
- Zhong-Qun Zhan
- Department of Cardiology, Shenzhen Hospital-University of Chinese Academy of Sciences, Shenzhen, P.R. China
| | - Yang Li
- Department of Cardiology, Shenzhen Hospital-University of Chinese Academy of Sciences, Shenzhen, P.R. China
| | - Li-Hao Wu
- Department of Cardiology, Shenzhen Hospital-University of Chinese Academy of Sciences, Shenzhen, P.R. China
| | - Li-Hong Han
- Department of Cardiology, Shenzhen Hospital-University of Chinese Academy of Sciences, Shenzhen, P.R. 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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Chen S, Wang H, Huang L. The presence of De Winter electrocardiogram pattern following elective percutaneous coronary intervention in a patient without coronary artery occlusion: A case report. Medicine (Baltimore) 2020; 99:e18656. [PMID: 32000371 PMCID: PMC7004660 DOI: 10.1097/md.0000000000018656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE The De Winter electrocardiogram (ECG) pattern is considered as a ST elevated myocardial infarction (STEMI)-equivalent pattern. Due to its rare nature, it is unclear whether this ECG pattern suggests the presence of some other condition. PATIENT CONCERNS We reported a 47-year-old man with new-onset chest discomfort several hours after the second-stage percutaneous coronary intervention (PCI). DIAGNOSES An emergency coronary angiogram (CAG) did not show any abnormality. However, the dynamic changes in the ECG and myocardial biomarkers indicated perioperative myocardial infarction. INTERVENTION The patient was monitored in the cardiac care unite (CCU), and was administered an intravenous infusion of diltiazem and subcutaneous injection of low molecular weight heparin. OUTCOMES After a few hours, his symptoms were alleviated. The patient was discharged after 6 days of hospitalization without any complications. LESSONS The De Winter ECG pattern can be observed in patients without significantly coronary arteries occlusion. The newly onset De Winter ECG pattern after PCI procedure may indicate perioperative myocardial infarction caused by impaired microvascular perfusion.
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Affiliation(s)
- Shi Chen
- Department of Cardiology, West China Hospital, Sichuan University
| | - Hua Wang
- Department of Cardiology, West China Hospital, Sichuan University
| | - Liwei Huang
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Cardiovascular Ultrasound and Non-invasive Cardiology Department, Affiliated Hospital of University of Electronic Science and Technology of China, Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, Chengdu, Sichuan, P.R. 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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