de Winter pattern: Is it always so typical?

Atypical de Winter Presentation of Critical Left Anterior Descending Coronary Artery Occlusion

“…In light of the existing data, we postulate that in our case by the time our patient presented to the emergency room, the de Winter ST depressions had already been evolving to the concave ST elevations, leading to an atypical presentation of the de Winter pattern rather a classical presentation. We also hypothesize that the tall, symmetric, T-waves seem to be the most characteristic of de Winter syndrome as well as ischemia as that seems to be the persistent finding in cases that report atypical presentations [ 3 , 13 , 15 ]. We contribute to the existing data by reporting a case of critical LAD stenosis which presented as an atypical de Winter pattern and led to a delayed diagnosis and attest to the lack of awareness of this ECG pattern among physicians.…”

“…It has also been described that ST elevations can evolve into de Winter ECG pattern [ 12 ]. Hence, based on the existing data, two patterns of de Winter have been proposed [ 3 , 13 ], namely, static presentation with persistent J-point depression before revascularization, and a dynamic pattern that may evolve into ST elevation. Furthermore, recent reports of atypical presentations of de Winter have been published.…”

“…Interestingly, an acute right coronary artery occlusion was described with a typical de Winter pattern in the inferolateral leads with upsloping ST-segment depression at the J-point continuing into positive symmetrical T-waves in leads II, III, aVF, and V4-V6, coupled with ST-segment elevation in lead aVR [ 15 ]. Yalta et al described these atypical presentations and raised the question of whether atypical de Winter might be more prevalent and have a higher propensity to be missed as they do not conform to the classical pattern [ 3 ].…”

“…Although the underlying electrophysiological explanation for these ECG changes is not entirely known, few theories have been proposed. These findings have been attributed to certain anatomical variants such as an anatomical variant of Purkinje fibers with endocardial conduction delay [ 2 ], preexisting ECG changes [ 3 ], or the existing collateral blood supply which prevents the myocardium from transmural ischemia, hence preventing ST-segment elevation [ 10 ]. Alternatively, lack of activation of sarcolemmal ATP-sensitive potassium (KATP) channels by ischemic depletion of ATP can also explain the absence of ST elevation, evidenced by the acute ischemia models of KATP knockout animals [ 16 ].…”

“…They found that this ECG pattern is consistent with the proximal LAD conclusion in 2% of patients who presented with acute coronary syndromes. However, more recent studies have described atypical variants of the de Winter pattern that did not strictly follow the classical de Winter criteria, and are still considered and treated as ST-segment elevation myocardial infarction (STEMI) equivalents [ 3 ]. In our case, the typical presence of tall symmetrically positive T-waves in precordial leads was associated with concave ST-segment elevations rather than depressions and a subtle aVR elevation.…”