What is a De Winter ECG pattern?

De Winter ECG Pattern: A STEMI Equivalent

The De Winter ECG pattern is a STEMI equivalent characterized by upsloping ST-segment depression at the J point in leads V1-V6 with tall, symmetrical T waves, often associated with acute proximal left anterior descending coronary artery (LAD) occlusion requiring immediate reperfusion therapy.

Key Characteristics of De Winter ECG Pattern

• Upsloping ST-segment depression at the J point in precordial leads V1-V6 1
• Tall, symmetrical T waves in the precordial leads 1, 2
• J point elevation of approximately 1-2 mm in lead aVR 3
• Absence of classic ST-segment elevation in precordial leads 1
• Often associated with complete or subtotal occlusion of the proximal LAD 1, 4

Clinical Significance

The De Winter pattern is considered a STEMI equivalent that requires the same urgent management as ST-elevation myocardial infarction:

• Represents 2% of acute LAD occlusions 2
• Should prompt immediate cardiac catheterization and reperfusion therapy 4
• May be dynamic and can evolve into or from classic STEMI patterns 3
• Early recognition is critical for improving patient outcomes 4

Distinguishing Features from Other ECG Patterns

The De Winter pattern must be differentiated from:

1. Brugada Pattern:

   • Brugada shows coved ST-segment elevation with a negative T-wave in V1-V3 5
   • The "Corrado index" can help differentiate: in Brugada, the downsloping ST-segment has a STJ/ST80 ratio >1, while De Winter pattern shows upsloping ST-segment 5

2. Early Repolarization:

   • Early repolarization shows J-point elevation with concave ST-segment elevation 5
   • Early repolarization typically has an upsloping ST-segment with STJ/ST80 ratio <1 5

3. Normal Juvenile T-wave Inversion:

   • T-wave inversion in V1-V3 in patients under 16 years is a normal variant 6
   • Unlike De Winter pattern, juvenile pattern doesn't have the characteristic ST depression with tall T waves

Atypical Presentations

Some atypical presentations of De Winter pattern have been reported:

• De Winter pattern with concurrent ST elevation in inferior leads 1
• Dynamic changes where the pattern evolves into or from classic STEMI 3
• The pattern may be transient, reflecting subtotal rather than complete LAD occlusion 3

Management Approach

When De Winter pattern is identified:

1. Immediate Recognition: Recognize as a STEMI equivalent 2
2. Emergent Reperfusion: Arrange for immediate cardiac catheterization 4
3. Thrombolytic Therapy: Consider if PCI is not readily available 7
4. Serial ECGs: Monitor for dynamic changes as the pattern may evolve 3

Pitfalls to Avoid

• Failing to recognize this pattern as a STEMI equivalent, leading to delayed reperfusion
• Confusing with other causes of ST depression (demand ischemia, non-STEMI)
• Missing the diagnosis when the pattern is dynamic or atypical
• Delaying treatment while waiting for biomarker confirmation

The De Winter ECG pattern represents a critical finding that requires the same urgent attention and management as classic STEMI presentations. Recognizing this pattern can significantly impact patient outcomes through timely reperfusion therapy.