The de Winter ECG Pattern
The de Winter ECG pattern is a specific electrocardiographic finding characterized by ST-segment depression and tall, prominent, symmetrical T waves in the precordial leads, which represents an equivalent to ST-elevation myocardial infarction (STEMI) and indicates acute occlusion of the proximal left anterior descending (LAD) coronary artery.
Characteristics of the de Winter Pattern
The de Winter pattern consists of several distinct features:
- 1-3 mm upsloping ST-segment depression at the J-point in precordial leads (particularly V1-V6)
- Tall, prominent, symmetrical T waves in the precordial leads
- Absence of classic ST-segment elevation in the affected leads
- Often accompanied by slight ST-segment elevation (0.5-1 mm) in lead aVR
Clinical Significance
This pattern has significant clinical importance for several reasons:
- It occurs in approximately 2% of patients with acute occlusion of the proximal LAD 1
- It represents a STEMI-equivalent that requires immediate intervention 2
- It may be a transient finding that evolves into a more typical STEMI pattern 1
- Recognition is critical as it indicates the need for emergency coronary angiography and reperfusion therapy
Pathophysiology
The exact mechanism behind the de Winter pattern is not fully understood, but it likely represents:
- Acute transmural ischemia affecting the anterior wall of the left ventricle
- Altered ventricular repolarization due to severe myocardial ischemia
- A variant of the hyperacute T wave phase of myocardial infarction
Differential Diagnosis
The de Winter pattern must be distinguished from:
- Hyperkalemia (which can also cause tall, peaked T waves)
- Left ventricular hypertrophy with strain pattern
- Early repolarization (which typically has concave ST elevation rather than depression)
- Wellens' syndrome (which features biphasic or deeply inverted T waves)
Management Implications
Recognition of the de Winter pattern should prompt:
- Immediate activation of the cardiac catheterization laboratory
- Emergency coronary angiography
- Primary percutaneous coronary intervention (PCI) of the occluded LAD
- Standard acute coronary syndrome management protocols
Evolution and Variants
The de Winter pattern may:
- Evolve into a typical STEMI pattern with ST-segment elevation 1
- Present as a transient finding during the course of acute myocardial infarction 2
- Occasionally occur without significant coronary artery occlusion, possibly due to microvascular dysfunction 3
- Present as an atypical pattern that may be considered a "mirror image" of ST elevation in some cases 4
Clinical Pitfalls
- The pattern may be misinterpreted as non-specific ST-T wave changes, leading to delayed intervention
- It can coexist with other ECG abnormalities, making recognition more challenging 5
- It is not included in many traditional STEMI criteria, potentially leading to underrecognition
Understanding and recognizing the de Winter pattern is essential for emergency physicians, cardiologists, and any clinicians interpreting ECGs in patients with chest pain, as prompt recognition can significantly impact morbidity and mortality outcomes through timely reperfusion therapy.