Other Causes of De Winter Waves in ECG Beyond Acute Coronary Syndromes
While De Winter ECG pattern is strongly associated with acute proximal left anterior descending coronary artery occlusion, it can occasionally be seen in other clinical scenarios that should be considered in differential diagnosis.
What is De Winter Pattern?
De Winter pattern is characterized by:
- Upsloping ST-segment depression at the J point in precordial leads V1-V6 1
- Tall, prominent, and symmetrical T waves in the precordial leads 1, 2
- Possible ST elevation in lead aVR 2
- Usually associated with acute proximal LAD occlusion 1, 2
Other Causes of De Winter Pattern
1. Diagonal Branch Lesions
- Isolated diagonal branch occlusion can mimic the classic De Winter pattern even when the LAD itself is intact 3
- This has been documented in cases of spontaneous coronary artery dissection affecting diagonal branches 3
2. Transient Presentations
- De Winter pattern can appear transiently and resolve without intervention in some cases 3
- May represent a dynamic coronary lesion that spontaneously improves 4
3. Early Phase of Evolving STEMI
- De Winter pattern may represent an early evolutionary phase of acute myocardial infarction 4
- Can transform into classic STEMI pattern if left untreated 4, 5
- Should be recognized as a "STEMI equivalent" requiring urgent intervention 5
4. Non-Coronary Causes to Consider in Differential Diagnosis
- Acute pericarditis may show ST changes that could be confused with De Winter pattern 6
- Left ventricular hypertrophy can cause ST-T changes that may mimic ischemic patterns 6
- Stress cardiomyopathy (Takotsubo) can present with ST-T changes 6
- Early repolarization patterns may show some similarities 6
- Brugada syndrome has distinctive ECG patterns that could be confused with anterior ischemia 6
Clinical Implications and Management
Recognition and Response
- De Winter pattern occurs in approximately 2% of anterior myocardial infarctions 2
- Should be treated as a STEMI equivalent with urgent cardiac catheterization 2, 5
- Failure to recognize this pattern may lead to delayed treatment of critical coronary occlusion 1
Diagnostic Approach
- Compare with previous ECGs when available 6
- Consider serial ECGs to detect evolution of pattern 6
- Evaluate for clinical context (chest pain characteristics, risk factors) 6
- Use cardiac biomarkers to help differentiate causes 6
Important Caveats
- The presence of De Winter pattern should always raise high suspicion for LAD occlusion first 1, 2
- Non-coronary causes should only be considered after excluding acute coronary syndrome 6
- Even when caused by diagonal branch lesions rather than LAD occlusion, De Winter pattern still represents acute coronary syndrome requiring intervention 3
- Transient patterns may still indicate significant underlying coronary pathology 4, 3