What is the management of a patient with De Winter's ECG (electrocardiogram)?

Management of De Winter's ECG Pattern

Patients with De Winter's ECG pattern should be managed as STEMI equivalents with immediate activation of the cardiac catheterization laboratory and urgent coronary reperfusion via primary PCI with a goal of first medical contact-to-device time of ≤90 minutes. 1, 2

Recognition of De Winter's ECG Pattern

De Winter's ECG pattern is characterized by:

• Upsloping ST-segment depression at the J point in precordial leads
• Tall, prominent, and symmetric T waves
• Absence of classic ST-segment elevation
• Highly specific for acute occlusion or critical stenosis of the proximal left anterior descending (LAD) coronary artery 2, 3

Initial Management Algorithm

1. Immediate Recognition and Triage:

   • Obtain 12-lead ECG within 10 minutes of first medical contact 1
   • Recognize De Winter pattern as a STEMI equivalent 3, 4
   • Activate cardiac catheterization team immediately 1

2. Pre-Catheterization Management:

   • Administer aspirin 325 mg
   • Establish IV access
   • Provide supplemental oxygen only if SaO2 < 90%
   • Consider titrated IV opioids for pain relief (with caution due to potential delayed uptake of oral antiplatelet agents) 2
   • Initiate dual antiplatelet therapy with aspirin and a P2Y12 inhibitor 2
   • Begin anticoagulation with unfractionated heparin, low molecular weight heparin, or bivalirudin 2

3. Reperfusion Strategy:

   • Primary PCI is the preferred reperfusion strategy with target door-to-balloon time <90 minutes 1, 2
   • If PCI is not available within 120 minutes, consider fibrinolytic therapy if no contraindications exist 2, 5, 6
   • Early advance notification of the receiving PCI-capable hospital by EMS personnel is recommended to reduce time to reperfusion 1

Monitoring During Treatment

• Continuous ECG monitoring for arrhythmias and dynamic changes 2
• Serial ECGs if initial ECG is non-diagnostic but clinical suspicion remains high 2
• Hemodynamic monitoring for signs of cardiogenic shock or heart failure 1
• Echocardiography to assess left ventricular function and rule out mechanical complications 2

Special Considerations

• In rural or non-PCI capable facilities, immediate transfer to a PCI-capable center is recommended 1
• If transfer will delay reperfusion >120 minutes and symptoms started <12 hours ago, fibrinolytic therapy should be considered in the absence of contraindications 5, 6
• For patients with ongoing symptoms and high clinical suspicion despite initially non-diagnostic ECG, maintain high vigilance and consider repeat ECGs every 15-30 minutes 2

Common Pitfalls to Avoid

• Delayed recognition: De Winter pattern is often misinterpreted as non-STEMI or unstable angina, leading to delayed reperfusion 3, 4
• Waiting for biomarkers: Do not delay reperfusion therapy while awaiting troponin results 2
• Relying on computer interpretation: Computer algorithms may not recognize De Winter pattern; manual expert interpretation is essential 2
• Insufficient monitoring: Patients may develop classic STEMI pattern or hemodynamic instability; continuous monitoring is critical 7, 6

De Winter's ECG pattern represents a critical diagnosis that requires the same urgency in management as classic STEMI. Early recognition and immediate reperfusion therapy are essential to improve outcomes and reduce mortality in these patients.