De Winter pattern: a forgotten pattern of acute LAD artery o
The De Winter ECG pattern was reported as an indicator of acute left anterior descending (LAD) coronary artery occlusion and is considered an anterior ST-elevation myocardial infarction (STEMI) equivalent. The key diagnostic features include ST-depression and peaked T-waves in precordial leads, and it can be seen in around 2% of patients with anterior myocardial infarction.

Published in BMJ, the authors report a case of a 77-year-old woman with history of treated hypertension and hypercholesterolaemia. She presented to the emergency department with a typical acute chest pain, almost 1 hour after symptom onset.

An ECG was immediately obtained and revealed sinus bradycardia at 45 bpm, with 1–2 mm ST-depression at the J point that continued into a wide, tall, positive, symmetrical T-wave in leads V2–V6, and a 0.5 mm ST-elevation in lead aVR. She was immediately transferred to our primary coronary intervention (PCI) centre.

The ECG monitoring on arrival at the catheterization laboratory displayed persistent ST-depression and tall T-waves in precordial leads. Coronary angiography showed a culprit lesion in the proximal LAD artery, which was occluded (TIMI-0 flow).

The remaining coronary arteries exhibited non-significant disease. Primary PCI of the proximal LAD artery was performed 145 min after STEMI diagnosis. A drug-eluting stent was implanted with good clinical and angiographic result (TIMI-3 flow).

The Wellens’ syndrome is another example of an unrecognised high-risk presentation of anterior ischaemia, and it is characterised by deeply inverted or biphasic T waves in multiple precordial leads.

In conclusion, missing these high-risk ECG patterns as reversible severe ischaemia may lead to undertreatment of patients with a STEMI, and implies negative effects on morbidity and mortality.

Learning points
• The De Winter ECG pattern typically displays tall T-waves, but the static nature and characteristic ST-depression differentiates this pattern from hyperacute T-waves.

• The De Winter ECG pattern and the Wellens’ syndrome should prompt the suspicion of a proximal left anterior descending occlusion, as both are considered anterior ST-elevation myocardial infarction equivalents.

• The immediate recognition of these ECG changes is essential for referring patients to urgent reperfusion therapy and may have important prognostic implications.

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