A 48-year old man was admitted to the Emergency Department with severe chest pain of 1-hour duration. He was a current smoker with a smoking history of 10 pack-year. The electrocardiogram (ECG; Figure 1.) showed upsloping ST-segment depression with tall, symmetric and positive T waves in leads V2 through V5 and loss of precordial R-wave progression. The result of an initial troponin I test was normal. This upsloping ECG pattern of ST-segment depression that continues into tall, symmetric T waves in the precordial leads — also known as the De Winter pattern — has been associated with total occlusion of left anterior descending coronary artery. This pattern is considered an ST-elevation myocardial infarction (STEMI) equivalent and emergent percutaneous coronary intervention seems warranted1-3. The patient underwent emergent coronary angiography that showed complete occlusion of the mid left anterior descending coronary artery and percutaneous coronary intervention with stent placement was performed. The echocardiogram showed mildly depressed left ventricular ejection fraction. The patient began guideline-directed medical therapy and was discharged home five days after the event. He received smoking-cessation counselling and was referred to a cardiac rehabilitation program.
Recognition of characteristic changes in an electrocardiogram that are associated with acute occlusion of a coronary artery guides decisions regarding immediate reperfusion therapy2,3,4. This case intends to highlight an under-recognized ECG pattern that is estimated to be present in about 2% of patients with acute anterior myocardial infarction1,2 and should be followed by timely reperfusion therapy whereas it is considered a STEMI equivalent3-5.
Figura I
Figure 1. ECG pattern showing upsloping ST-segment depression with tall, symmetric and positive T waves in the precordial leads (red arrows) and loss of precordial R-wave progression
BIBLIOGRAFIA
1. Zhao YT, Huang YS. ECG Pattern Associated with Left Anterior Descending Coronary Artery Occlusion. N Engl J Med. 2018; 378:e22.
2. de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008; 359:2071-3.
3. Elias BH, Glancy DL. The de Winter Electrocardiographic Pattern of Proximal Left Anterior Descending Coronary Artery Occlusion. Am J Cardiol. 2016; 118(7):1095-6.
4. Morris NP, Body R. The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review. Eur J Emerg Med. 2017; 24(4):236-242.
5. Martínez-Losas P, Fernández-Jiménez R. de Winter syndrome. CMAJ. 2016; 19 188(7): 528.
