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The De Winter ECG pattern: morphology and accuracy for diagnosing acute coronary occlusion: systematic review
1University of Manchester and Central Manchester NHS Foundation Trust, Manchester, UK.
Insights
The De Winter ECG pattern, often seen as an ST elevation myocardial infarction (STEMI) equivalent, shows high positive predictive value for acute coronary occlusion. Further research is needed to confirm its specificity and impact on mortality.
Area of Science:
- Cardiology
- Electrocardiography
- Emergency Medicine
Background:
- The De Winter ECG pattern is recognized as a potential indicator of acute left anterior descending coronary artery occlusion.
- It is frequently considered an ST elevation myocardial infarction (STEMI) equivalent, necessitating prompt diagnosis and intervention.
Purpose of the Study:
- To investigate the specific morphological characteristics of the De Winter ECG pattern.
- To evaluate the diagnostic accuracy, particularly the test characteristics, of the De Winter pattern for identifying acute coronary occlusion.
Main Methods:
- A systematic literature search was conducted using Medline, EMBASE, and COCHRANE databases.
- Papers were screened for bias using QUADAS-2. ECG measurements were aggregated, and diagnostic accuracy data from cohort studies were extracted.
- The primary outcome was defined as at least 70% angiographic stenosis of a major epicardial vessel.
Main Results:
- Analysis of 13 relevant papers revealed consistent ECG findings: maximal up-sloping ST depression in lead V3 (median amplitude 0.3 mV) and peaked T-waves in lead V3 (median amplitude 0.9 mV).
- Three diagnostic studies reported high positive predictive values for the De Winter pattern: 95.2%, 100%, and 100% for acute coronary occlusion.
- The De Winter pattern demonstrated a high positive predictive value, suggesting its utility in diagnosing acute occlusive events.
Conclusions:
- The De Winter ECG pattern exhibits a high positive predictive value for acute coronary occlusion.
- While considered a potential STEMI equivalent, further research is required to establish its specificity and the clinical benefit of rapid revascularization in patients presenting with this pattern.
Abstract:
The De Winter ECG pattern has been reported to indicate acute left anterior descending coronary artery occlusion and is often considered to be an 'ST elevation myocardial infarction (STEMI) equivalent'. We aimed to investigate the morphology of the 'De Winter ECG pattern' and evaluate the test characteristics of the De Winter pattern for the diagnosis of acute coronary occlusion. We identified papers through the Medline, EMBASE and COCHRANE databases and screened for bias using QUADAS-2. First, measurements were recorded from every ECG reported in the literature and aggregated. Second, diagnostic accuracy data from eligible cohort studies were extracted. The primary outcome was defined as at least 70% angiographic stenosis of a major epicardial vessel. Thirteen papers reported data relevant to question 1 and three papers reported data relevant to question 2. All ECGs showed maximal up-sloping ST depression in lead V3 with a median amplitude of 0.3 mV (interquartile range: 0.2-4 mV). T-wave height peaked in lead V3 with a median amplitude 0.9 mV (interquartile range: 0.8-1.1 mV). The De Winter pattern had positive predictive values of 95.2% (95% confidence interval: 76.2-99.9%), 100% (69.2-100.0%) and 100% (51.7-100%) in the three respective diagnostic studies. There is limited evidence that the De Winter ECG pattern is a 'STEMI equivalent'. The available data suggest that the pattern has high positive predictive value for acute occlusion. Further research is required to evaluate specificity and to determine whether rapid revascularization improves mortality.