The de Winter ECG pattern: Distribution and morphology of ST depression

Abstract

Background The reported positive predictive value (PPV) for the “de Winter ECG pattern” to predict an acute left anterior descending artery (LAD) lesion is inconsistent. Besides, the morphology of upsloping or nonupsloping ST depression (STD) may have different significance of severity and prognostication. Methods We searched the MEDLINE database using “de Winter” or “junctional ST‐depression with tall symmetrical T‐waves” or “tall T wave” or “STEMI equivalent” as the item up to March 2020. We compared the ECG differences between the different culprit arteries and various morphological STD. Results A total of 70 patients with analyzable ECGs were included. In 60 patients (LAD group), the LAD was the culprit artery, while in 10 patients (non‐LAD group), there were other etiologies. Maximal STD in V2 or V3 had a PPV of 89% of all patients and 98% of patients without ST elevation in V2 to detect an acute LAD lesion. The presence of q/Q‐wave or poor R‐wave progression in the precordial leads was significantly more often found in patients with upsloping STD than in patients with nonupsloping STD in the LAD group (84% vs. 27%, p < .01). In 18 patients, the ECG showed a change from upsloping to nonupsloping STD from the leads with maximal STD to the surrounding leads with less STD. Conclusions The location of the maximal STD in the precordial leads differs between patients with LAD as the culprit artery and other etiologies of the de Winter ECG pattern. Upsloping STD signifies more severe signs of ischemia than nonupsloping STD.

The de Winter electrocardiographic pattern evolves to ST elevation in acute total left main occlusion: A case series

“…The location of the upsloping STD in the precordial leads seemed to be associated with the culprit artery. A systematic review of 70 cases of the de Winter ECG pattern reported that upsloping STD from V 2 to V 4 centered on V 3 had a high positive predictive value for LAD occlusion (Zhan, Li, Han, et al, 2020 ). Tsutsumi K (Tsutsumi & Tsukahara, 2018 ) reported a case of a de Winter pattern in leads II, III, aVF, and V 4 –V 6 associated with a predominantly large RCA culprit in an inferoposterior myocardial infarction.…”

Dynamic evolvement of the de Winter ECG pattern

“…Initially, the de Winter ECG pattern was considered a stable condition until reperfusion (Winter et al., 2008). However, several studies have demonstrated that this ECG pattern may be a transient ECG phenomenon (Zhan et al., 2020). In our case, we observed a dynamic evolution from the de Winter ECG pattern to STEMI within four hours, which was associated with an occlusion proximal to the LAD artery, as (Wei‐Wei et al., 2019) reported.…”

The de Winter Pattern as Pre-Anterior ST-Elevation-Myocardial-Infarction. “An Evolution Sequence”: A Case Report

“…10,13 The shape of the ST depression may denote the difference of severity and extent of myocardial ischemia, anatomical different, and myocardial protection with the upsloping pattern was the most severe form than non-upsloping (horizontal and downsloping) for the dWP. 14 Subendocardial ischemia in the early time results dWP to appear, when ischemia is progressed into transmural ischemia the STEMI pattern will appear with classic diastolic and systolic current of injury mechanism. It can be hypothesized that there was a time when the ischemia expanded from the subendocardium to the epicardium that showed the evolution of the STsegment.…”