Going Beyond Left Anterior Descending Artery Occlusion: Recognizing the Variable Clinical Associations of the de Winter Pattern on Electrocardiography

Abstract

We read with keen interest the case reported by García-Izquierdo et al. 1 García-Izquierdo E. Parra-Esteban C. Mirelis J. et al. The De Winter ECG pattern in the absence of acute coronary artery occlusion. Can J Cardiol. 2018; 34: 209.e1-e3 Abstract Full Text Full Text PDF Scopus (8) Google Scholar in a recent issue of the Canadian Journal of Cardiology. The authors' contribution is greatly appreciated because it illustrates the danger of yoking a pattern on the electrocardiogram (ECG) to an eponymous syndrome. García-Izquierdo et al. report a 26-year-old man who presented with exertional chest pain radiating to the left arm, marked elevation of troponin I levels at 15.62 μg/L (normal value < 0.06 μg/L) and the classic ECG of anterior upsloping ST-segment depression with tall T waves first described by de Winter et al. in 2008. 2 de Winter R. Verouden N. Wellens H. et al. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008; 359: 2071-2073 Crossref PubMed Scopus (249) Google Scholar In that seminal article, de Winter identified a relatively small case series of 30 patients with such a pattern but without ST-segment elevation who were subsequently found to have total occlusion of the left anterior descending (LAD) coronary artery. This pattern is estimated to represent the presentation of 2% of patients with acute anterior myocardial infarction. Nevertheless, in the current case report, emergent coronary angiography demonstrated no coronary lesions. Instead, subsequent cardiac magnetic resonance imaging findings were compatible with myocarditis, and the ECG and biomarkers normalized before the patient's discharge. The de Winter ECG Pattern in the Absence of Acute Coronary Artery OcclusionCanadian Journal of CardiologyVol. 34Issue 2PreviewA 26-year-old man presented to the emergency department with chest pain and electrocardiogram (ECG) changes compatible with the de Winter pattern. Emergent coronary angiography was used to rule out the presence of significant stenosis. Cardiac magnetic resonance imaging confirmed the diagnosis of myocarditis. This case underlines the lack of data regarding the positive predictive value of this ECG pattern for the diagnosis of acute myocardial infarction. Until further prospective studies are available, we believe that the de Winter ECG pattern should be considered as an “ST-elevation equivalent” when myocardial ischemia is suspected. Full-Text PDF