What is the management approach for De Winter syndrome?

Management of De Winter Syndrome

De Winter syndrome requires immediate reperfusion therapy via primary percutaneous coronary intervention (PCI) as it represents a STEMI equivalent associated with proximal left anterior descending artery occlusion. 1, 2

What is De Winter Syndrome?

De Winter syndrome is a specific ECG pattern characterized by:

• Upsloping ST-segment depression >1 mm at the J-point in precordial leads
• Tall, prominent, symmetrical T waves in the precordial leads
• 0.5-1 mm ST-segment elevation in lead aVR
• Absence of classic ST-segment elevation 1

This pattern is associated with proximal left anterior descending (LAD) coronary artery occlusion and represents approximately 2% of acute myocardial infarctions 3.

Diagnostic Recognition

Early recognition is critical as this pattern indicates a STEMI equivalent that requires emergency reperfusion:

• The ECG pattern may be transient and evolve into classic STEMI 4
• It should be recognized as a "very-high-risk" pattern requiring immediate intervention 1
• Serial ECGs may be necessary as the pattern can change rapidly 5

Management Algorithm

1. Initial Recognition and Assessment (0-10 minutes)

• Identify the characteristic De Winter ECG pattern
• Obtain vital signs and brief focused history
• Establish IV access
• Administer aspirin 325 mg chewed
• Consider P2Y12 inhibitor (ticagrelor preferred over clopidogrel) 1

2. Immediate Management (10-30 minutes)

• Classify as "immediate invasive strategy" requiring catheterization within 2 hours 1
• Initiate anticoagulation (unfractionated heparin, enoxaparin, or bivalirudin) 1
• Provide supplemental oxygen if saturation <90%
• Consider nitroglycerin for ongoing chest pain
• Transfer immediately to cardiac catheterization laboratory 2

3. Reperfusion Strategy

• Primary PCI is the preferred reperfusion strategy 2, 6
• If PCI is not available within 2 hours, consider immediate transfer to PCI-capable facility 1
• If transfer is not possible and symptoms <12 hours, consider fibrinolytic therapy as per STEMI protocol 1

4. Post-Reperfusion Care

• Dual antiplatelet therapy (aspirin plus P2Y12 inhibitor)
• High-intensity statin therapy
• Beta-blocker therapy (if no contraindications)
• ACE inhibitor or ARB for patients with LVEF ≤40% 1
• Monitor for complications (arrhythmias, heart failure, mechanical complications)

Special Considerations

• De Winter syndrome may represent an early pattern in the evolution of anterior STEMI 4
• The pattern may be missed if clinicians are not specifically looking for it 2
• Patients with this pattern have a high mortality risk if reperfusion is delayed 2
• In bifurcation lesions, special techniques may be required to protect side branches during PCI 6

Common Pitfalls to Avoid

1. Misdiagnosis as non-STEMI: Despite lacking classic ST elevation, this pattern requires STEMI-level urgency 5
2. Delayed intervention: Waiting for troponin results or serial ECGs showing classic STEMI changes may result in increased myocardial damage 2
3. Inappropriate triage: These patients should be triaged to the STEMI pathway, not the NSTEMI pathway 1
4. Failure to recognize pattern evolution: The ECG pattern may evolve between De Winter pattern and classic STEMI 4

De Winter syndrome represents a critical diagnosis requiring the same urgency as STEMI. Early recognition and immediate reperfusion therapy via primary PCI is essential to reduce mortality and improve outcomes.