Thrombolysis for De Winter Syndrome When Percutaneous Coronary Intervention is Delayed: A Critical Review

The de Winter electrocardiogram pattern, recognized as a critical STEMI-equivalent signaling proximal left anterior descending artery occlusion, presents a persistent dilemma in clinical practice: while primary percutaneous coronary intervention remains the definitive treatment, current guidelines offer no clear direction on thrombolysis-a gap particularly consequential in resource-limited settings where timely intervention is often unfeasible. To navigate this uncertainty, this review critically examines the underlying pathophysiology, synthesizes the often conflicting historical evidence, and integrates recent systematic findings with contemporaneous case reports. Historically, evidence supporting thrombolysis has been limited to isolated, inconsistent case reports, leaving clinicians without reliable guidance. A pivotal shift emerges from a 2025 systematic review, which offers the first quantitative synthesis, demonstrating that nearly 80% of patients receiving thrombolysis achieved successful reperfusion-a figure that reframes the risk-benefit calculus. Beyond efficacy, recent case data highlight essential nuances for patient selection; for instance, certain conditions like spontaneous coronary artery dissection can mimic the de Winter pattern but constitute absolute contraindications to thrombolytic therapy, underscoring the necessity for precise diagnostic differentiation. Consequently, in scenarios where primary PCI is delayed beyond 120 min, thrombolysis emerges as a viable and potentially lifesaving bridging strategy for carefully selected patients exhibiting the classic ECG findings. This pharmaco-invasive approach, however, demands rigorous clinical assessment and must be followed by immediate, mandatory transfer to a PCI-capable center to ensure comprehensive care.