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

De Winter's ECG: Not your usual STEMI

We report a 39-year-old male who presented with severe chest pain and diaphoresis who suffered from pulseless polymorphic ventricular tachycardia en route to the hospital. His initial electrocardiogram showed De Winter's Pattern (dWP). Coronary angiography revealed 100% thrombotic ostial occlusion of the left anterior descending artery. In young males presenting with chest pain and diaphoresis, dWP should be part of a clinician's differential diagnosis when analyzing the initial electrocardiogram. The medical community needs increased awareness to prevent delay of revascularization because dWP is an ST-segment elevation myocardial infarction (STEMI) equivalent and does not present like a typical STEMI on electrocardiogram.

Clinical outcomes in acute coronary syndrome after presentation of unique electrocardiographic findings

BACKGROUND

Unique electrocardiographic findings are rarely observed in acute coronary syndrome (ACS) with a culprit left anterior coronary artery (LAD). The aim of this study was to assess the epidemiological features and prognostic impact.

METHODS

This study was designed as an observational study. A total of 641 patients with a culprit lesion in the left main trunk or LAD were extracted from a cohort of 1776 ACS patients. The primary endpoint was mortality, comparing patients presenting with unique electrocardiogram patterns, specifically the de Winter pattern or Wellens' syndrome (type A or B), upon hospital arrival, with those presenting common electrocardiogram patterns.

RESULTS

A unique electrocardiogram was observed in 7.0% (n = 45; 2 with de Winter pattern, 14 with Wellens' type A and 29 with type B). Compared to patients with a common pattern, cardiogenic shock at hospital arrival were rare in patients with a unique pattern (0% vs. 8.4%, P = 0.04), and percutaneous coronary intervention was primary revascularization strategy in all groups (95.6% vs. 98.2%). The mortality rates were similar between the two groups over a median 565 days of observation period (13.3% vs. 15.7%, P = 0.43), with 0% in Wellens' type A, 13.8% in type B, and both patients with the de Winter pattern died.

CONCLUSION

The de Winter pattern or the Wellens syndrome was found in 7.0% of cases with ACS. They had similar mortality rates compared to those with a common pattern, although the de Winter pattern was identified in only 2 patients.

Context-independent identification of myocardial ischemia in the prehospital ECG of chest pain patients

Non-traumatic chest pain is a frequent reason for an urgent ambulance visit of a patient by the emergency medical services (EMS). Chest pain (or chest pain-equivalent symptoms) can be innocent, but it can also signal an acute form of severe pathology that may require prompt intervention. One of these pathologies is cardiac ischemia, resulting from a disbalance between blood supply and demand. One cause of a diminished blood supply to the heart is acute coronary syndrome (ACS, i.e., cardiac ischemia caused by a reduced blood supply to myocardial tissue due to plaque instability and thrombus formation in a coronary artery). ACS is dangerous due to the unpredictable process that drives the supply problem and the high chance of fast hemodynamic deterioration (i.e., cardiogenic shock, ventricular fibrillation). This is why an ECG is made at first medical contact in most chest pain patients to include or exclude ischemia as the cause of their complaints. For speedy and adequate triaging and treatment, immediate assessment of this prehospital ECG is necessary, still during the ambulance ride. Human diagnostic efforts supported by automated interpretation algorithms seek to answer questions regarding the urgency level, the decision if and towards which healthcare facility the patient should be transported, and the indicated acute treatment and further diagnostics after arrival in the healthcare facility. In the case of an ACS, a catheter intervention room may be activated during the ambulance ride to facilitate the earliest possible in-hospital treatment. Prehospital ECG assessment and the subsequent triaging decisions are complex because chest pain is not uniquely associated with ACS. The differential diagnosis includes other cardiac, pulmonary, vascular, gastrointestinal, orthopedic, and psychological conditions. Some of these conditions may also involve ECG abnormalities. In practice, only a limited fraction (order of magnitude 10%) of the patients who are urgently transported to the hospital because of chest pain are ACS patients. Given the relatively low prevalence of ACS in this patient mix, the specificity of the diagnostic ECG algorithms should be relatively high to prevent overtreatment and overflow of intervention facilities. On the other hand, only a sufficiently high sensitivity warrants adequate therapy when needed. Here, we review how the prehospital ECG can contribute to identifying the presence of myocardial ischemia in chest pain patients. We discuss the various mechanisms of myocardial ischemia and infarction, the typical patient mix of chest pain patients, the shortcomings of the ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) ECG criteria to detect a completely occluded culprit artery, the OMI ECG criteria (including the STEMI-equivalent ECG patterns) in detecting completely occluded culprit arteries, and the promise of neural networks in recognizing ECG patterns that represent complete occlusions. We also discuss the relevance of detecting any ACS/ischemia, not necessarily caused by a total occlusion, in the prehospital ECG. In addition, we discuss how serial prehospital ECGs can contribute to ischemia diagnosis. Finally, we discuss the diagnostic contribution of a serial comparison of the prehospital ECG with a previously made nonischemic ECG of the patient.

Acute coronary syndrome with simultaneous two-vessel occlusion De Winter ST-segment depression or reciprocal change?

We discuss a case of acute coronary syndrome (ACS) with simultaneous two-vessel occlusions in a man in his 20s. The serial electrocardiograms (ECG) showed very early dynamic changes of ST-T configuration resulting from ischemic zone depth or area between anterior wall versus inferior wall. The upsloping ST depression along with tall tentorial T waves in the precordial leads, as shown in the index ECG, raises the possibilities of a de Winter pattern. The retrospective assessment of the index ECG identified prominent T waves and a mild degree of ST-segment elevations in the inferior leads, given the electrocardiographic findings previously recorded at his workplace medical examination obtained at a later date. If the subtle ST-segment elevations in leads II, III, and aVF and the tall T waves were not overlooked in the index ECG, the probability of reciprocal ST-segment depressions in the precordial leads should also be taken into account. We recognize our ECG findings as intriguing ST-T deviation patterns that can change depending on the time sequence and anatomical dominancy of two infarct-related arteries. We finally suggest physicians should bear in mind the possibility of simultaneous multiple vessel occlusions when they encounter ACS patients with hemodynamic instability as in this present case.

ECGs in Critical Care Cardiology: Do Not Miss That Myocardial Infarction

This paper provides clinical cases of acute myocardial infarction that do not show ST-segment elevation on 12-lead electrocardiogram, but should be clinically treated as ST-segment elevation myocardial infarction with early diagnostic coronary angiogram followed by appropriate strategy of revascularization. (Level of Difficulty: Beginner.).

The De Winter-like electrocardiogram pattern associated with multi-vessel disease

Background

The de Winter ECG pattern was described by upsloping ST‐segment depression in leads V1‐V6, tall and symmetrical T waves in precordial leads. The ECG pattern is regarded to be associated with occlusion of the left anterior descending (LAD) artery.

Methods

One patient with de Winter ECG pattern was included. The 12‐lead ECG of patients with chest pain showed upsloping ST‐segment depression up to 3 mm at the J point in leads V2‐V6; tall symmetrical T waves in leads V2‐V4; 1mm J point elevation in lead aVR; ST‐segment depression 1mm in I, aVL leads and inverted T waves in the inferior leads. The ECG was showed the de Winter pattern.

Results

The ECG was showed the de Winter pattern. CAG was performed, which showed the normal left main; 60%‐80% LAD stenosis; 50%‐60% ostial right coronary artery(RCA) stenosis; and 90% stenosis of the vessel at middle segment. Both proximal and middle RCA vascular lesions were dilated and successfully inserted with drug‐eluting stents, respectively.

Conclusion

Our case the ECG was showed horizontal ST depression with tall T waves in leads V2‐V4 (maximal ST depression in lead V4) while only ST depression in leads V5‐V6, which may result from multivessel disease.

The Role of ECG in the Diagnosis and Risk Stratification of Acute Coronary Syndromes: an Old but Indispensable Tool

PURPOSE OF REVIEW

Since its inception in 1902 by Willem Einthoven, the electrocardiogram (ECG) has fundamentally undergone minimal technological advances. Nevertheless, its clinical utility is critical, and it remains an essential tool to diagnose, risk stratify, and guide reperfusion and invasive strategies in patients with suspected acute coronary syndromes. ECG reading can be demanding, with many healthcare professionals lacking the necessary expertise to accurately interpret them. This is exacerbated by the need to constantly revisit old dogmas pertinent to the interpretation of ECGs.

RECENT FINDINGS

Notably, ECG leads record the global electrical activity of the heart toward and away from each electrode rather than local events. The long-held central paradigm that the various ECG leads record local events underneath specific electrodes should therefore be reassessed. For example, ST segment elevation in leads V1 and V2 usually denote antero-apical rather than septal infarction, often a misnomer utilized by the majority of clinicians. The ECG diagnosis of ST-elevation myocardial infarction (STEMI) is sometimes challenging and discerning it from non-ST-elevation myocardial infarction (NSTEMI) is of paramount importance to implement timely acute reperfusion therapy. In fact, when qualifications for emergency reperfusion therapy are based on STEMI ECG criteria, nearly one-third of cases with acute coronary occlusion are missed. Diagnostic ST elevation in the absence of left ventricular (LV) hypertrophy or left bundle-branch block (LBBB) is defined by a specific set of sex-specific criteria for new ST elevation at the J point in contiguous precordial or limb leads. However, other ECG criteria need to be kept in mind. These include, but are not limited to, new or presumably new left bundle branch block (LBBB), which is often considered as an STEMI-equivalent; ST depression in two or more precordial leads (V1-V4), denoting a true inferolateral transmural myocardial infarction; and the infrequent presentation with hyperacute T-wave changes. As our understanding of the pathology of ischemic reperfusion injury has evolved and following the introduction of new imaging modalities such as cardiac magnetic resonance imaging, we need to re-assess the old dogmas pertinent to the interpretation of ECGs and update the terms and classifications.

Atypical de Winter ECG pattern may be the mirror image of ST elevation

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.

Dynamic evolvement of the de Winter ECG pattern

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.

The de Winter electrocardiographic pattern evolves to ST elevation in acute total left main occlusion: A case series

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.

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.