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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 48-50

Thrombolysis in the de winter electrocardiography pattern: A therapeutic dilemma


1 Department of Medicine, ESIC Postgraduate Institute of Medical Sciences and Research, New Delhi, India
2 Scientist-C, Indian Council of Medical Research, New Delhi, India
3 Department of Pharmaceutical Science, Maharshi Dayanand University, Rohtak, Haryana, India

Date of Submission27-Jan-2022
Date of Decision01-Apr-2022
Date of Acceptance06-Apr-2022
Date of Web Publication26-Apr-2022

Correspondence Address:
Amit Kumar
Department of Medicine, ESIC Postgraduate Institute of Medical Sciences and Research, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_4_22

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  Abstract 


The de Winter's pattern is an electrocardiography (ECG) finding characterized by ST depression and tall prominent T-waves in precordial leads with ST elevation in lead aVR. It signifies the occlusion of proximal left anterior descending artery (LAD). Although it is considered a ST-elevation myocardial infarction (STEMI) equivalent, current guidelines recommend against the use of thrombolytic therapy in the absence of STEMI. As the question whether to use thrombolysis in such situations remains unanswered and controversial, we preferred to provide thrombolytic therapy with tenecteplase to our patient admitted with acute retrosternal chest pain with de Winter's ECG pattern so as to prevent myocardial damage and improve the patient outcome as the percutaneous coronary intervention facility was not immediately available. The thrombolysis was successful and the proximal LAD occlusion was confirmed later on coronary angiography which was treated with stent implantation. This case report tends to highlight the therapeutic dilemma while managing patients with de Winter's ECG pattern.

Keywords: de Winter's pattern, electrocardiography, STEMI equivalents, thrombolysis


How to cite this article:
Kumar A, Chetiwal R, Tanwar S, Gupta S, Kumar R. Thrombolysis in the de winter electrocardiography pattern: A therapeutic dilemma. J Pract Cardiovasc Sci 2022;8:48-50

How to cite this URL:
Kumar A, Chetiwal R, Tanwar S, Gupta S, Kumar R. Thrombolysis in the de winter electrocardiography pattern: A therapeutic dilemma. J Pract Cardiovasc Sci [serial online] 2022 [cited 2022 May 25];8:48-50. Available from: https://www.j-pcs.org/text.asp?2022/8/1/48/344128




  Introduction Top


ST-elevation myocardial infarction (STEMI) equivalents are the electrocardiography (ECG) patterns which do not strictly meet the criteria for STEMI but still indicate significant coronary obstruction.[1],[2] The de Winter pattern, first described in 2008 by de Winter et al., characterized by ST elevation in lead aVR with multilead ST depression in ECG, is one of the STEMI equivalents and has been described to be associated with acute occlusion of proximal left anterior descending artery (LAD), left main coronary artery, and myocardial infarction (MI) in the setting of multivessel coronary artery disease.[3] This condition requires urgent intervention, typically percutaneous stent placement; however, in the absence of percutaneous coronary intervention (PCI) facility, the management remains controversial. Here, we report a case of acute chest pain with de Winter ECG pattern treated successfully with thrombolytic therapy in the situation of nonavailability of immediate primary coronary intervention.


  Case Report Top


A 58-year-old male presented to the emergency department with a history of chest pain of 2-h duration, radiating to the left shoulder and left upper limb. There was no previous history of such episodes. He was a nonsmoker, nonalcoholic, with no past medical history of diabetes, hypertension, stroke, or MI. On examination, the patient was conscious, oriented with pulse rate and blood pressure of 84/min and 130/70 mmHg, respectively. Cardiovascular and respiratory examinations were within the normal limits. His oxygen saturation (SpO2) was 97% on room air. The first 12-lead ECG revealed upsloping ST depressions at the J point (>1 mm) with symmetric tall, peaked T-waves in leads V4-V6, ST-elevation lead aVR and V1, and ST-segment depression in the inferior leads [Figure 1]. This ECG did not meet the classic STEMI criteria; however, it was characteristic of the rare de Winter's pattern. The cardiac troponin T was positive, and creatine kinase-MB was also elevated. All other laboratory investigation values were within the normal range. In the setting of nonavailability of the facility for primary coronary intervention and the requirement of immediate reperfusion therapy in view of persistent severe chest pain, it was decided to provide thrombolytic therapy with tenecteplase. The chest pain subsided in an hour, and ECG showed a significant reversal of ST-segment changes [Figure 2]. The coronary angiography performed the next day revealed 90% occlusion of the proximal LAD, which was successfully treated by PCI with a drug-eluting stent [Figure 3]. The 2-D echocardiography showed no regional wall motion abnormalities and an ejection fraction of 55%. The patient was later discharged under the stable condition on dual antiplatelet therapy, statin, and beta-blocker.
Figure 1: ECG showing de Winter's pattern. ECG: Electrocardiography

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Figure 2: Postthrombolysis ECG showing significant reversal of initial ST-segment and T-wave changes. ECG: Electrocardiography

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Figure 3: Coronary angiography showing occlusion of proximal LAD (a) and successful opening after stent placement (b). LAD: Left anterior descending artery

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  Discussion Top


The STEMI equivalents are the patterns which may mimic STEMI, but do not meet the criteria and include posterior MI, de Winter's, Wellens, delayed activation wave, and T-wave precordial instability.[1],[2] Robbert de Winter, in a 2008 case series, observed that around 2% of patients with anterior wall MI had atypical ECG changes and had proximal LAD occlusion. This pattern which was called the de Winter pattern include (i) tall, prominent, symmetrical T-waves in the precordial leads, (ii) upsloping ST-segment depression >1 mm at the J point in the precordial leads, (iii) absence of ST elevation in the precordial leads, (iv) reciprocal ST-segment elevation (0.5 mm–1 mm) in aVR, and (v) typical STEMI morphology may precede or follow the de Winter pattern. As the de Winter can evolve into STEMI, it is important for cardiologists and emergency care physicians to recognize this distinct ECG pattern, so they can triage such patients for immediate reperfusion therapy.[4],[5] The positive predictive value of de Winter's pattern has been reported to be 100% (with a 95% confidence interval of 69.2%–100.0%), 95.2% (76.2%–99.9%), and 100% (51.7%–100%) by several studies.[5],[6],[7] The exact pathophysiological phenomenon underlying de Winter's pattern has not been fully established; however, the ischemic depletion of adenosine triphosphate (ATP) due to critical subocclusion of LAD and the subsequent alteration in the functioning of sarcolemmal ATP-sensitive potassium channels causes the lack of typical ST elevations which may ultimately progress to transmural ischemia in the absence of collateral blood flow.[3],[8],[9] Despite the significant implications of this ECG pattern, the 2017 European Society of Cardiology and 2013 American Heart Association guidelines do not classify this as a STEMI equivalent. As the patients with de Winter's pattern have a considerably higher mortality in the setting of MI, this should be considered a STEMI equivalent and should be urgently treated with reperfusion therapy, preferably with primary PCI. However, when PCI cannot be offered timely, thrombolytic therapy may be considered in a patient with ongoing severe chest pain strongly suggestive of acute MI. Rao et al. successfully thrombolyzed two cases of de Winter's pattern and suggested that thrombolytic therapy may be a choice for de Winter pattern patients when cardiac catheterization laboratory cannot be activated emergently.[10] Similarly, Shergill et al. successfully treated a patient with angina and de Winter's pattern with streptokinase with complete resolution of symptoms and ECG returning to baseline.[11] In the same context, we considered offering thrombolytic therapy to our patient, which we did successfully, and later, the finding of proximal LAD occlusion on angiographic study confirmed the diagnosis.


  Conclusion Top


The de Winter's pattern signifies the underlying occlusion of the proximal LAD and demands prompt recognition and immediate reperfusion therapy to improve the overall patient outcome. Although primary PCI is the modality of choice, thrombolytic therapy may be considered in such patients in case of nonavailability of immediate and urgent PCI facilities.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Ethics clearance

Written informed consent was obtained from the patient. Institutional ethics committee was informed about the case report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wall J, White LD, Lee A. Novel ECG changes in acute coronary syndromes. Would improvement in the recognition of 'STEMI-equivalents' affect time until reperfusion? Intern Emerg Med 2018;13:243-9.  Back to cited text no. 1
    
2.
Rokos IC, French WJ, Mattu A, Nichol G, Farkouh ME, Reiffel J, et al. Appropriate cardiac cath lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction. Am Heart J 2010;160:995-1003.  Back to cited text no. 2
    
3.
de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA; Interventional Cardiology Group of the Academic Medical Center. A new ECG sign of proximal LAD occlusion. N Engl J Med 2008;359:2071-3.  Back to cited text no. 3
    
4.
Wang H, Dai XC, Zhao YT, Cheng XH. Evolutionary de Winter pattern: From de Winter ECG to STEMI – A case report. BMC Cardiovasc Disord 2020;20:324.  Back to cited text no. 4
    
5.
Verouden NJ, Koch KT, Peters RJ, Henriques JP, Baan J, van der Schaaf RJ, et al. Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion. Heart 2009;95:1701-6.  Back to cited text no. 5
    
6.
Sclarovsky S, Rechavia E, Strasberg B, Sagie A, Bassevich R, Kusniec J, et al. Unstable angina: ST segment depression with positive versus negative T wave deflections – Clinical course, ECG evolution, and angiographic correlation. Am Heart J 1988;116:933-41.  Back to cited text no. 6
    
7.
Misumida N, Kobayashi A, Schweitzer P, Kanei Y. Prevalence and clinical significance of up-sloping ST-segment depression in patients with non-ST-segment elevation myocardial infarction. Cardiol Res 2015;6:306-10.  Back to cited text no. 7
    
8.
Li RA, Leppo M, Miki T, Seino S, Marbán E. Molecular basis of electrocardiographic ST-segment elevation. Circ Res 2000;87:837-9.  Back to cited text no. 8
    
9.
Birnbaum Y, Wilson JM, Fiol M, de Luna AB, Eskola M, Nikus K. ECG diagnosis and classification of acute coronary syndromes. Ann Noninvasive Electrocardiol 2014;19:4-14.  Back to cited text no. 9
    
10.
Rao MY, Wang YL, Zhang GR, Zhang Y, Liu T, Guo AJ, et al. Thrombolytic therapy to the patients with de Winter electrocardiographic pattern, is it right? QJM 2018;111:125-7.  Back to cited text no. 10
    
11.
Shergill GS, Singh A, Meena NK. De Winters pattern: Spotted and successfully thrombolysed with streptokinase. Heart India 2017;5:157.  Back to cited text no. 11
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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