Is early invasive management as ST elevation myocardial infarction warranted in de Winter's sign?-a "peak" into the
Joel M Raja1, Amit Nanda2, Issa Pour-Ghaz2
1Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
Insights
De Winter's sign on an EKG indicates acute proximal left anterior descending coronary artery occlusion. Prompt recognition and early intervention, such as percutaneous coronary intervention, are crucial for better outcomes in this STEMI equivalent.
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Electrocardiography
Background:
- De Winter's sign is an EKG pattern indicating acute proximal left anterior descending (LAD) coronary artery occlusion.
- It presents with ST depression and hyper-acute T waves in precordial leads, unlike typical ST-elevation myocardial infarction (STEMI).
- This sign is found in approximately 2% of anterior myocardial infarctions.
Purpose of the Study:
- To review the diagnostic characteristics and management strategies for De Winter's sign.
- To determine the optimal timing and mode of intervention for patients presenting with this EKG pattern.
- To emphasize the importance of recognizing De Winter's sign as a STEMI equivalent.
Main Methods:
- Systematic literature search of Medline and other relevant databases (published before June 1, 2019).
- Keywords included "de Winter's sign," "STEMI equivalent," "cardiac catheterization," and "thrombolysis."
- Inclusion of pivotal trials, practice guidelines, and relevant reviews, with author consensus for narrative inclusion.
Main Results:
- De Winter's sign signifies severe coronary artery pathology, often LAD occlusion, associated with high mortality.
- Early recognition and intervention are critical for improving patient outcomes.
- Evidence supports treating De Winter's sign as a STEMI equivalent, necessitating prompt cardiac catheterization and percutaneous coronary intervention (PPCI).
Conclusions:
- De Winter's sign, though rare, requires immediate attention due to its association with critical LAD occlusion.
- Early activation of the cardiac catheterization lab and PPCI are recommended for optimal treatment.
- Prompt recognition and intervention can lead to significantly better outcomes in patients with De Winter's sign.
Abstract:
de Winter's sign was first described by de Winter et al. in 2008 as a new electrocardiographic (EKG) pattern of acute proximal left anterior descending coronary artery (LAD) occlusion. Instead of the normal presentation of ST elevation, it is described as depression of ST segment at the J point in the precordial leads V1-V6, which are upsloping leading to hyper-acute T waves, with ST elevation in aVR. The initial retrospective systematic analysis proved this sign to be present in about 2% of anterior myocardial infarction. This review aims to address the important question of mode and urgency of intervention, on detection of de Winter's sign. In this review, we take a look at the de Winter's sign EKG characteristics, accuracy in diagnosis, typical patient presentation, and the outcomes of early intervention. We conducted a Medline search using various combinations of "de Winter's sign," "STEMI equivalent," "cardiac catheterization," and "thrombolysis" to identify pivotal research articles published before June 1, 2019, for inclusion in this review. Concurrently, major practice guidelines, trial bibliographies, and pertinent reviews were examined to ensure inclusion of relevant trials. A consensus among the authors was used to choose items for narrative inclusion. The following section reviews data from pivotal trials to determine the need for early invasive management in de Winter's sign. Research articles reviewed evaluating cardiac catheterization in de Winter's sign. de Winter's sign, although rare (~2%), should be promptly recognized, as it reveals underlying severe coronary artery pathology, frequently involving the LAD which is associated with a high rate of mortality. This systematic review emphasizes awareness and strong consideration of early activation of the cardiac catheterization lab with PPCI; which may yield better treatment outcomes. The evidence suggests that de Winter's sign, presenting with ST depression and T wave elevation, should indeed be treated as ST-elevation myocardial infarction (STEMI) equivalent, with prompt recognition and early intervention.
Related Concept Videos
01:30Acute Coronary Syndrome I: Introduction
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:14Myocarditis III: Medical Management
01:26Mitral Stenosis III: Medical Management
01:18Endocarditis III: Medical Management
01:22Myocarditis IV: Nursing Management