Case Report: De Winter electrocardiographic pattern associated with acute total left main coronary artery occlusion

The de Winter electrocardiograph (ECG) pattern is a well-established ST-elevation myocardial infarction (STEMI) equivalent, most commonly associated with acute occlusion of the proximal left anterior descending (LAD) artery.

A 54-year-old man presented to the emergency department with two hours of chest pain, sweating, and nausea. The 12-lead ECG showed upsloping J-point depression in leads V2-V6 and lead I, with tall, symmetrical T waves in leads V2-V5, ST-segment elevation in lead aVR, and ST-segment depression in the inferior leads, consistent with the de Winter pattern. Emergency coronary angiography revealed total occlusion of the left main coronary artery (LMCA), and a drug-eluting stent was implanted. Due to refractory heart failure and worsening hemodynamics, the patient underwent intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO) treatment. The patient was discharged 40 days later.

This case demonstrates that the de Winter ECG pattern may occasionally indicate LMCA occlusion rather than isolated LAD occlusion. In the setting of a de Winter ECG pattern accompanied by inferior lead ST-segment depression and ST-segment elevation in lead aVR, clinicians should raise clinical suspicion for LMCA occlusion-particularly in hemodynamically unstable patients-to facilitate timely and comprehensive intervention.