Man with chest pain.

CASE PRESENTATION

A 61‐year‐old man with a history of hypertension and hyperlipidemia presented to the emergency department complaining of a constant left‐sided chest pain present for 1 hour. On examination, his vital signs were normal other than a blood pressure of 180/100 mmHg. He was diaphoretic with an unremarkable cardiopulmonary examination. An echocardiogram (ECG) was performed (Figure 1).

FIGURE 1

de Winter pattern characterized by upsloping ST‐segment depression at the J point in leads V1 to V6 with associated tall and symmetrical T waves. Abbreviation: aVR, augmented vector right lead

DIAGNOSIS

de Winter pattern

First described in 2008, the de Winter pattern on ECG is present in 1.6%–3.4% of anterior wall myocardial infarctions (AWMI). , , , It is characterized by upsloping ST‐segment depression at the J point in the leads V1 to V6 with associated tall, symmetrical T waves. The majority of patients also have ST‐segment elevation in the augmented vector right lead and poor R‐wave progression across the precordial leads, though these 2 features are not essential to make the diagnosis.

The de Winter pattern is seen early in the course of AWMI, typically within the first 90 minutes of symptom onset. , It has a positive predictive value of over 95% for AWMI. It is considered by many to be a ST‐segment elevation myocardial infarction equivalent and an indication for emergent reperfusion therapy. , ,

The vast majority of patients with a de Winter pattern seen on ECG will have occlusion of the proximal left anterior descending coronary artery or one of its main branches , , (Figure 2). Patients with the de Winter pattern as an electrocardiographic manifestation of AWMI are more likely to be male, younger, and with hyperlipidemia.

FIGURE 2

The patient's cardiac catheterization revealing a 100% occlusion of the proximal left anterior descending artery (arrow)