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Identification of the STEMI-equivalent de Winter Electrocardiogram Pattern After Ventricular Fibrillation
Michael J Carr1, James T O'Shea2, Patrick B Hinfey2
1Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, New Jersey.
Insights
The de Winter ECG pattern, a STEMI equivalent, was observed after cardiac arrest. Prompt recognition of this pattern is crucial for timely reperfusion therapy in patients with chest pain.
Area of Science:
- Cardiology
- Emergency Medicine
- Electrocardiography
Background:
- ST-elevation myocardial infarction (STEMI) poses a high risk for patients with chest pain and ST elevations on ECG.
- STEMI equivalents, such as the de Winter pattern, are critical to recognize as they indicate significant cardiac events.
- The de Winter pattern is characterized by ST depressions and hyperacute T-waves in precordial leads, linked to proximal left anterior descending artery occlusion.
Observation:
- A case report details a 33-year-old male presenting with chest pain and initial non-specific ECG changes.
- The patient experienced ventricular fibrillation cardiac arrest, after which the de Winter ECG pattern emerged.
- Post-resuscitation ECGs revealed the characteristic de Winter pattern, including ST depressions and hyperacute T-waves.
Findings:
- The de Winter ECG pattern, typically associated with acute coronary syndromes, was identified following ventricular fibrillation cardiac arrest.
- This case highlights the de Winter pattern's occurrence in a non-atherosclerotic context, post-cardiac arrest.
- The ECG changes initially normalized before the cardiac arrest, then reappeared.
Implications:
- Emergency physicians must be aware of the de Winter pattern as a STEMI equivalent to avoid misdiagnosis.
- Delayed recognition can lead to prolonged transport and delayed reperfusion therapy.
- Prompt identification and intervention in a cardiac catheterization laboratory are essential for optimal patient outcomes.
Background:
Patients with chest pain who have ST elevations on electrocardiogram (ECG) are at high risk for ST-elevation myocardial infarction (STEMI). Recent literature has reported various STEMI equivalents, which may be equally threatening. One STEMI equivalent, previously named the de Winter pattern, describes ECG changes where there are ST-segment depressions in the precordial leads in association with tall, symmetrical, hyperacute T-waves. These changes have been connected with proximal left anterior descending coronary artery occlusion.
Case Report:
We have identified a case of the de Winter ECG pattern immediately after ventricular fibrillation cardiac arrest. A 33-year-old man presented with waxing and waning severe substernal chest pain. The patient was on no prior medications, and had no risk factors for acute coronary syndrome. The initial ECG showed ST depression, which was followed by normalization in a repeat ECG only minutes later. The patient then developed ventricular fibrillation cardiac arrest. After defibrillation, return of spontaneous circulation was achieved and subsequent ECGs demonstrated the de Winter ECG pattern. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The characteristic ECG changes within the de Winter ECG pattern may be missed or misdiagnosed as nonspecific, reversible ischemia. This can significantly lengthen the transportation to a center equipped with a percutaneous coronary intervention laboratory, and thus the start of reperfusion therapy. It is imperative that all practitioners learn to identify this novel ECG pattern as a STEMI equivalent to ensure appropriate intervention in the cardiac catheterization laboratory.
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