De Winter Pattern: Clinical Significance and Management
What is the De Winter Pattern?
The De Winter ECG pattern is a STEMI-equivalent that indicates critical proximal left anterior descending (LAD) artery occlusion requiring immediate emergency reperfusion therapy, not observation or delayed intervention. 1, 2
The pattern consists of:
- Upsloping ST-segment depression >1 mm at the J-point in the precordial leads (maximal in V3, median amplitude 0.3 mV) 3, 4
- Tall, prominent, symmetrical T waves arising from the upsloping ST depression (peaking in V3 with median amplitude 0.9 mV) 3, 4
- 0.5-1 mm ST-segment elevation in lead aVR 3
Critical Clinical Context
This pattern represents a pre-infarction state occurring at the early stage of anterior STEMI, not a stable or benign finding 1, 5. The pattern is transient, with median evolution to typical STEMI occurring within 114 minutes 5. Missing this diagnosis leads to delayed reperfusion and increased risk of extensive anterior wall infarction 3, 1.
The prevalence is approximately 3.4% among patients with anterior myocardial infarction 5. The culprit lesion is typically in the proximal LAD or diagonal branch 5.
Immediate Management Algorithm
Step 1: Recognition and Risk Stratification
- Classify immediately as high-risk NSTE-ACS requiring urgent catheterization laboratory activation 1
- The pattern should be immediately recognizable to paramedics, emergency physicians, and anyone responsible for catheterization laboratory activation 2, 1
- Initiate continuous ECG monitoring to detect life-threatening arrhythmias 1
Step 2: Initial Medical Therapy
- Administer aspirin 162-325 mg if no contraindications 1
- Consider nitroglycerin for symptom relief if chest pain is present 1
- Do NOT delay reperfusion therapy for additional testing
Step 3: Reperfusion Strategy
Primary PCI is the definitive treatment and should be implemented within 120 minutes of first medical contact 1:
- Patients presenting within 12 hours of symptom onset require immediate reperfusion 1
- Radial access is preferred over femoral access to reduce bleeding and vascular complications 1
- The positive predictive value for acute coronary occlusion is 95-100% 4
If PCI cannot be performed within 120 minutes:
- Consider fibrinolytic therapy if no contraindications exist 1
- However, patients with De Winter pattern respond poorly to thrombolytic therapy 5, 6
- This poor response to thrombolytics makes primary PCI strongly preferred over pharmacologic reperfusion 5
Step 4: Special Timing Considerations
- Patients presenting 12-48 hours after symptom onset: Still consider routine primary PCI strategy 1
- Patients presenting >48 hours after symptom onset and asymptomatic: Routine PCI of occluded infarct-related artery is NOT indicated 1
Post-Intervention Care
- Guideline-directed medical therapy: Beta-blockers, ACE inhibitors, and statins 1
- Risk factor modification before discharge 1
- Most patients will develop ST-segment elevation, pathologic Q waves, and loss of R wave progression on follow-up ECGs 5
Critical Pitfalls to Avoid
Misdiagnosis Traps
Do not confuse De Winter pattern with:
- Deeply inverted T waves with QT prolongation (Wellens' syndrome or CVA pattern) - these show T-wave inversion >0.5 mV in V2-V4, not tall upright T waves 3, 1
- Cardiomyopathy-related T-wave changes 3
- Other causes of ST depression (demand ischemia, posterior MI) 3
Management Errors
- Do not treat as stable angina or NSTE-ACS requiring observation - this is a STEMI-equivalent 1, 2
- Do not rely on thrombolytic therapy as primary strategy - PCI is strongly preferred given poor thrombolytic response 5
- Do not wait for ST-segment elevation to develop - the pattern itself mandates immediate action 5, 2
Additional Diagnostic Considerations
If the initial 12-lead ECG is non-diagnostic but clinical suspicion remains high: