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The de Winter's pattern revisited: a case series
Thadathilankal-Jess John1, Alfonso Pecoraro1, Hellmuth Weich1
1Division of Cardiology, Department of Medicine Stellenbosch University & Tygerberg Academic Hospital PO Box 241, Cape Town 8000, South Africa.
Insights
The de Winter ECG pattern, indicating proximal LAD occlusion, may evolve into STEMI. Thrombolytic therapy is a viable option when primary PCI is delayed, underscoring the pattern's high-risk nature.
Area of Science:
- Cardiology
- Emergency Medicine
- Electrocardiography
Background:
- The de Winter ECG pattern, associated with proximal LAD occlusion, was initially believed to be static.
- Previous recommendations favored primary PCI for managing this condition.
Purpose of the Study:
- To investigate the dynamic nature of the de Winter ECG pattern.
- To evaluate management strategies for patients presenting with the de Winter ECG pattern.
Main Methods:
- Presentation and management of two distinct cases with the de Winter ECG pattern.
- Case 1: Initial de Winter pattern progressing to anterior STEMI, treated with emergency PCI.
- Case 2: De Winter pattern managed with a pharmacoinvasive strategy due to PCI time constraints, followed by stenting.
Main Results:
- The de Winter pattern evolved into STEMI in one case, suggesting it is not static.
- Resolution of the de Winter pattern was observed following reperfusion therapy.
- Both cases involved significant Left Anterior Descending (LAD) artery occlusion.
Conclusions:
- The de Winter ECG pattern may represent a dynamic stage of ischaemia, potentially progressing to STEMI.
- Thrombolytic therapy can be considered when timely primary PCI is not feasible.
- Early recognition and intervention for the de Winter pattern are crucial due to its high-risk nature.
Background:
The de Winter's electrocardiogram (ECG) pattern signifying proximal left anterior descending (LAD) artery occlusion was first described in 2008. The ECG changes were thought to be static and mechanisms for this were suggested. In addition, the optimal management of these patients was reported to be via a primary percutaneous coronary intervention (PCI) strategy.
Case Summary:
Case 1: A 48-year-old gentleman presented with a 2-h history of ischaemic chest pain with initial de Winter's pattern on ECG. This progressed to anterior ST-elevation myocardial infarction (STEMI) complicated by ventricular fibrillation. Emergency angiography revealed a mid-vessel LAD occlusion which was successfully reperfused. Case 2: A 34-year-old female presented with a 2-h history of ischaemic chest pain with initial ECG showing a de Winter's pattern. Due to concerns of performing PCI timeously, a pharmacoinvasive strategy of reperfusion was adopted with resolution of the de Winter's pattern. Urgent angiography revealed a proximal LAD lesion which was successfully stented.
Discussion:
The two cases highlight that the de Winter's pattern may in fact not be static, but rather lie along the continuum of ischaemia and may evolve into STEMI. In addition, we provide further evidence that if primary PCI cannot be offered in a timeous manner, thrombolytic therapy may be considered in such patients. The de Winter's pattern remains a high-risk ECG pattern that requires early recognition and intervention.
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