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

Recognition and Diagnosis

• De Winter's ECG pattern is characterized by:

  • Upsloping ST-segment depression at the J point in precordial leads
  • Tall and prominent symmetrical 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 1

• Obtain a 12-lead ECG within 10 minutes of first medical contact for patients with chest pain 1

• Do not rely solely on computer ECG interpretation, as this pattern may be missed 1

• Compare with previous ECGs if available to assess changes 1

Immediate Management

1. Cardiac Catheterization Laboratory Activation

   • Activate cardiac catheterization team immediately upon recognition of De Winter's pattern 1
   • Target door-to-balloon time <90 minutes 1

2. Initial Medical Therapy

   • Establish IV access
   • Administer aspirin 325 mg
   • Provide supplemental oxygen only if SaO2 < 90% 2
   • Administer titrated IV opioids for pain relief if needed 2
   • Consider mild tranquilizer (benzodiazepine) for anxious patients 2

3. Antiplatelet and Anticoagulation Therapy

   • Initiate dual antiplatelet therapy with aspirin and a P2Y12 inhibitor 1
   • Start anticoagulation with unfractionated heparin, low molecular weight heparin, or bivalirudin 1
   • Consider GP IIb/IIIa inhibitors for high-risk features 1

Reperfusion Strategy

• Primary PCI is the preferred reperfusion strategy 1

  • If available within 90-120 minutes of first medical contact

• Fibrinolytic Therapy

  • Consider if PCI is not available within 120 minutes and no contraindications exist 1
  • Particularly important in rural settings where timely transfer to PCI-capable centers is not possible 3

• Transfer Protocol

  • For patients presenting to non-PCI capable facilities, immediate transfer to a PCI-capable center is recommended 1
  • Early notification of the receiving PCI-capable hospital by EMS personnel is recommended to reduce time to reperfusion 1

Monitoring and Additional Assessment

• Continuous cardiac monitoring for arrhythmias
• Hemodynamic monitoring for signs of cardiogenic shock or heart failure 1
• Urgent echocardiography to:
  • Detect regional wall motion abnormalities
  • Assess left ventricular function
  • Rule out mechanical complications 1

Special Considerations and Pitfalls

• Common Pitfall: Failure to recognize De Winter's pattern as a STEMI equivalent, leading to delayed reperfusion 4

  • This pattern is associated with high mortality due to insufficient awareness 4

• Diagnostic Challenge: De Winter's pattern may transform into classic STEMI pattern over time 3

  • Do not delay reperfusion therapy while awaiting biomarker results 1

• Rural Setting Challenges: In settings without immediate access to PCI:

  • Establish clear transfer protocols to PCI-capable centers
  • Consider thrombolysis if transfer delays are expected to exceed 120 minutes 5, 3
  • Maintain close monitoring during transfer for arrhythmias and hemodynamic instability 1

De Winter's ECG pattern represents a critical diagnosis requiring immediate action. Recognition of this pattern and prompt reperfusion therapy significantly impacts patient outcomes and survival.