De Winter Pattern Caused by a Large Diagonal Branch Culprit Lesion

J INVASIVE CARDIOL 2021;33(3):E230. 

Key words: cardiac imaging, electrocardiography, percutaneous coronary intervention

A 70-year-old man without previous cardiologic history was referred to the emergency department for an episode of ongoing chest pain during physical activity. The first electrocardiogram (ECG) showed downsloping ST-segment depression at the J-point and tall, symmetric T-waves in leads V3-V4 (Figure 1A). The first troponin I (TnI) determination was 0.18 ng/mL (normal value, <0.04 ng/mL); potassium levels on admission were completely normal. The patient underwent urgent coronary angiogram, which revealed a 75% stenosis in the left anterior descending (LAD) coronary artery and a total occlusion of a large diagonal branch (Figure 1B). Both stenoses were treated successfully with percutaneous coronary intervention (Figure 1C). Echocardiography revealed anterior free wall, septum, and apex akinesia. After reperfusion, the ECG developed negative T-waves in V2 through V6, DI, and aVL. The ECG pattern presented in this case, described in the literature as a “De Winter” pattern, is a possible manifestation of an acute anterior myocardial infarction due to LAD occlusion, with a reported incidence of 2%. 

The De Winter pattern should be promptly recognized and lead to the same approach (such as immediate coronary angiography) of an anterior ST-segment elevation pattern. In this case, which is the first described in the literature to the best of our knowledge, the pattern was the ECG expression of a culprit lesion located in a large diagonal branch rather than in the LAD.

From the ¹Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland; ²Division of Cardiology, Ospedale Civile Santi Antonio e Biagio e Cesare Arrigo, Alessandria, Italy; ³Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology – Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy; ⁴Division of Cardiology and Cardiac Intensive Care Unit, San Paolo Hospital, Savona, Italy; and ⁵Division of Cardiology, "Città della Salute e della Scienza di Torino" Hospital, Department of Medical Sciences, University of Turin, Turin, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted March 19, 2020.

Address for correspondence: Andrea Demarchi, MD, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland. Email: andrea.demarchi@cardiocentro.org