A middle-aged male patient with de Winter syndrome: a case report

ECG patterns suggestive of high-risk coronary anatomy in non-ST-segment elevation acute coronary syndrome - an analysis of real-world patients

Introduction

Electrocardiographic (ECG) patterns suggestive of high-risk coronary anatomy are indications for an urgent invasive approach in non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

Aim

To estimate the frequency of the observed phenomenon and assess the clinical characteristics of NSTE-ACS subjects associated with Wellens syndrome, the de Winter sign, or ST-segment depressions by ≥ 1 mm in ≥ 6 classic ECG leads with simultaneous ST-segment elevation in aVR and/or V1.

Material and methods

Out of 207 pre-screened subjects diagnosed with NSTE-ACS, 64 patients (26 women and 38 men) with complete medical records (including admission ECG and coronary angiography during the index hospitalization), and significant culprit stenosis or occlusion of the left main coronary artery (LMCA) or the proximal/middle segment of the left anterior descending artery (LAD) entered the final analysis. Clinical characteristics of patients exhibiting any of the high-risk ECG patterns was compared to their counterparts with significant lesions in LMCA or proximal/middle LAD without any of the high-risk ECG patterns.

Results

Among 64 patients with significant culprit lesions in LMCA or LAD, 19 (29.69%) exhibited one of the high-risk ECG patterns: Wellens syndrome (n = 10), the de Winter sign (n = 0), or multiple ST-segment depressions (n = 9). Clinical characteristics were comparable in 19 NSTE-ACS patients with the high-risk ECG patterns and their 45 counterparts.

Conclusions

Because ECG patterns suggestive of high-risk coronary anatomy are relatively frequent in patients with NSTE-ACS and culprit lesions in LMCA or LAD, their early recognition is of clinical importance.

Atypical de Winter Presentation of Critical Left Anterior Descending Coronary Artery Occlusion

A 69-year-old male presented with substernal chest pain that started a few hours earlier. On arrival, the patient was hemodynamically stable, and the physical examination was unrevealing. Laboratory workup revealed an elevated high-sensitivity troponin, and an initial electrocardiogram (ECG) revealed tall, symmetric T-waves with preceding minor concave ST-segment elevations less than 1 mm in the precordial leads (V1-V6) and 0.5 mm ST elevation in the aVR. Due to concerning ECG changes, the patient was treated for a possible non-ST-segment elevation myocardial infarction. A loading dose of aspirin and clopidogrel was given and a heparin drip was initiated. However, the patient's chest pain persisted requiring multiple sublingual nitroglycerin tablets. Later, on further review of the ECGs, the presence of de Winter T-waves was noted and led to activation of the catheterization laboratory, and an urgent left heart catheterization (LHC) was done. LHC revealed a critical 90% occlusion of the left anterior descending artery, and a drug-eluting stent was placed. The patient had a good recovery thereafter. This case emphasizes the rarity of the case and lack of awareness about the atypical de Winter pattern that is considered to be an ST-segment elevation myocardial infarction equivalent. Failure to recognize this can potentially lead to delayed intervention.