Atypical and delayed de Winter electrocardiograph pattern: A case report

Rationale: de Winter electrocardiograph (ECG) pattern signifies proximal left anterior descending coronary artery (LAD) occlusion and extensive anterior myocardial infarction, and it is found in about 2% of patients with proximal LAD occlusion. However, it is often unrecognized by physicians. In this case report, we present a patient with chest pain but showing an atypical and delayed de Winter ECG pattern. Patient concerns: A previously healthy 61-year-old man attended our emergency department with chest pain radiating to the left arm and back for 4 hours, who was without serious cardiovascular risk factors. ECG at emergency department showed no significant changes. High-sensitivity cardiac troponin I (hs-cTnI) was within normal limit. Diagnosis: At 5 hours after onset, ECG showed significant upsloping ST depression at J point in precordial leads V3 to V6, slight ST elevation in aVR and depression in inferior leads, and hs-cTnI peaked at 2.610 μg/L. The diagnosis of de Winter ECG pattern was confirmed by coronary angiography with an occlusion of the proximal LAD. Interventions: A stent was implanted through percutaneous coronary intervention. Outcomes: The patient's chest pain was relieved without further increase of hs-cTnI. ECG after procedure showed ST segment back to baseline in leads V4 to V6, but persistent ST elevation in V1 to V3 with QS or Q wave. Lessons: Timely diagnosis of de Winter ECG pattern is very important, especially the atypical an...
Source: Medicine - Category: Internal Medicine Tags: Research Article: Clinical Case Report Source Type: research

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Discussion:The management in this case is unfortunately common practice at many places around the world where we receive cases. Why would an interventionalist violate multiple recommendations from their own guidelines and watch at 10am while an LAD occlusion plays out in front of them? What could explain why some providers do not seem interested in the fact that LAD occlusion can be identified by something other than STEMI criteria? Or why the wall motion abnormality matching the distribution of concern is ignored? The only plausible explanation is that they have been taught that this is standard practice. Under the STEMI ...
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