De Winter pattern

Created by team@ekgdx.com on Jan. 2, 2024

Let’s talk about de Winter pattern.

This pattern is a novel sign that has been associated with left anterior descending coronary artery (LAD) occlusion.

Criteria

  • ST depression in precordial leads that continues into tall and symmetrical T waves.
  • ST elevation may be present in aVR and can be up to 2 mm. 

Note: The de Winter pattern holds significance as it is linked to the occlusion of the proximal left anterior descending coronary artery (LAD) when identified in the electrocardiogram (ECG) of individuals experiencing chest pain or displaying a history suggestive of acute coronary syndrome. In fact, this pattern is present in approximately 2% of patients diagnosed with proximal occlusion of the LAD.

 

Classic example

History

Although Dr. Robbert Jan de Winter is credited with initially describing it in 2008 in a letter to the editor of the New England Journal of Medicine, the indication of peaked T-waves as an indicator of myocardial ischemia was initially observed by Dr. William Dressler back in 1947 in a case series of over 27 patients. What Dr. de Winter characterized was “1- to 3-mm upsloping ST-segment depression at the J point in leads V1 to V6 that continued into tall, positive symmetrical T waves” that are often accompanied by a “1- to 2-mm ST-elevation in lead aVR”.

 

From the original paper by de Winter

 

From the original paper by Dressler 

 

Now I will show you several good examples from public sources. All credit to the authors and their sources, and my thanks for sharing these cases.

Courtesy of Emergency Medicine Guidewire

 

Courtesy of Rohan Madhu Prasad et al. American Heart Journal Plus: Cardiology Research and Practice. Volume 3, March 2021. 

 

Courtesy of @ShariqShamimMD from X (previously called Twitter)

Explanation of the pattern

The theoretical explanation for LAD occlusion without ST-segment elevation includes a potential anatomical variant of the Purkinje fibers causing endocardial conduction delay or the absence of activation of sarcolemmal adenosine triphosphate‐sensitive potassium channels due to ischemic ATP depletion (Verouden et al., 2009). However, the likely pathophysiologic background for the de Winter pattern involves regional subendocardial ischemia with myocardial protection through collateral circulation, ischemic preconditioning, or existing forward flow (Gorgels, 2009; Nikus, Pahlm, & Wagner, 2010). The evidence from this review further supports regional subendocardial ischemia as the underlying mechanism for the de Winter pattern. The upsloping ST depression and the tall, peaked T waves are explained physiologically by a hypoxia-driven alteration in ATP-dependent potassium channels, leading to a delay in repolarization in the subendocardial region and a change in the transmembrane action potential shape (Fiol Sala et al., 2015).

Remember:

If the patient has chest pain with clinical context suggestive of myocardial ischemia, this pattern should be considered a STEMI equivalent until proven otherwise. Therefore, this should include (besides other things): 

  • Bedside echocardiogram (looking for left ventricular wall motion abnormalities).
  • Immediate cardiology consult. 

Acting quickly and avoiding delays in this context can save many lives. Here is an interesting case which reflects what I just mentioned.

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References

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Thanks for joining us. 

Dr. Roig

de Winter pattern