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| CASE REPORT |
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| Year : 2017 | Volume
: 5
| Issue : 4 | Page : 157-159 |
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de Winters pattern: Spotted and successfully thrombolysed with streptokinase
GS Shergill, A Singh, NK Meena
Department of Medicine, Government Medical College and Guru Nanak Dev Hospital, Amritsar, Punjab, India
| Date of Web Publication | 28-Dec-2017 |
Correspondence Address:
G S Shergill
Flat Number 3, Registrar Flats, Government Medical College and Guru Nanak Dev Hospital, Amritsar - 143 001, Punjab
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/heartindia.heartindia_30_17
When it comes to management of acute coronary syndrome (ACS), no other investigation can replace the role electrocardiogram (ECG) that still holds the pivotal role in emergency rooms. Rightfully thence, the classification of ACS patients into ST elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) is based on these zig-zag lines on a squared paper strip. This classification is important as both the groups differ in their pathophysiology as well as management. While, thrombolysis or percutaneous coronary intervention is done in STEMI sufferers; thrombolysis is contraindicated in the ones with NTEMI. There are, however, some patterns which do not show obvious ST elevation in ECG but are in fact associated with critical narrowing of major heart vessels. de Winter is one such “NSTEMI-STEMI equivalent.” Although now widely agreed on as a STEMI equivalent, its management with streptokinase (STK) is controversial. We are reporting a case of 38-year-old male with chest pain, whose ECG revealed the classical de Winter pattern and was successfully thrombolysed with STK. Complete set of classical ECG tracings and its management with STK (perhaps first such report across the globe) are the two major highlights of this report.
Keywords: de Winter sign, ST elevation myocardial infarction equivalent, streptokinase, thrombolysis
How to cite this article:
Shergill G S, Singh A, Meena N K. de Winters pattern: Spotted and successfully thrombolysed with streptokinase. Heart India 2017;5:157-9 |
| Introduction | |  |
Described in 2009 and not a part of every standard scientific text yet, de Winters pattern is not easily recognised by emergency clinicians. Furthermore, there is controversy regarding its management with thrombolytics. Whereas the latest European Heart Association (EHA) and American Heart Association (AHA) guidelines don't recommend thrombolysis of de Winters, the majority publications on the subject are arriving from the western countries where the management is done with PCI. In the West, after the advent of PCI, thrombolysis has become obsolete from the scene as far as ACS is concerned- and the question doesn't hold any significance. On the contrary, in developing economies with poor public healthcare system, these much cheaper alternatives still hold a vital place.
| Case Report | | |
A 36-year-old obese male, chronic smoker with negative history of diabetes, hypertension presented in the emergency room of Government Medical College and Guru Nanak Dev Hospital with crushing type of intense pain in the left side of his chest that was radiating to the left arm for around 4.5 h. His blood pressure was 138/90 mmHg, pulse rate was recorded to be 102/min and SpO2 was recorded to be 91% at room air. The rest of the general physical and systemic examination was unremarkable. Immediate electrocardiogram (ECG) [Figure 1] was performed which revealed a very characteristic pattern with 2–6 mm upsloping ST-segment depression at the J point in the precordial leads, with tall and positive symmetric T waves with the ascending limb of the T wave commencing below the isoelectric baseline, loss of precordial R-wave progression, and ST-segment elevation of 1 mm in the lead aVR. The changes were most striking in lead V3. These ECG changes suggested de Winter syndrome, a condition associated with acute occlusion of the left anterior descending (LAD) coronary artery and no ST-segment elevation. Troponin T was measured to be as 1343 ng/ml (normal value is <0.01 ng/ml). Due to the unavailability of Cath-laboratory at our institute, the financial constraints of the patient and his consent to take the risk – we decided to thrombolyse the patient with streptokinase (STK). Second tracing was taken immediately after thrombolysis and it showed return of ST segment to the baseline, and normalization of tall T waves [Figure 2]. The third tracing was recorded 2 h after the thrombolysis and it showed complete disappearance of STE in aVR along with deeply inverted symmetric T waves-indicating reperfusion and successful thrombolysis [Figure 3]. It is worth mentioning that the patient became pain-free midway thrombolysis. 2D Echo was performed the following day and it showed mild hypokinesia of LAD territory with mildly depressed left ventricular function. The patient was discharged after 5 days in satisfactory condition with drug prescription, promise of smoking-cessation, and reduction of weight. | Figure 1: Electrocardiogram showing de Winter ST T complex in leads V2–V6, loss of precordial R-wave progression, and small ST-segment elevation in the aVR lead
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 | Figure 2: Electrocardiogram showing return of previous downward ST segment and tall T-waves to normal, STE in aVR has also resolved
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 | Figure 3: There is no ST elevation in aVR, T-waves have deeply inverted – suggesting reperfusion and successful thrombolysis
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| Discussion | | |
First recognized and reported by de Winter et al. in 2008[1] and later replicated in findings by Verouden et al.[2] in 2009; the ECG pattern showing >2 mm upsloping ST-segment depression at the J point in the precordial leads, with tall and positive symmetric T waves, ST-segment elevation of >0.5 mm in the lead aVR; is observed in about 2% patients with proximal LAD occlusion. The de Winter pattern could be confused with hyperacute T-waves which occur within minutes of coronary artery occlusion and progress rapidly to classical ST elevation myocardial infarction (STEMI) pattern.
Latest addition to the world of ECG after Bruadas and Wellens; this specific ECG pattern is seen in relatively young, predominantly male and those with higher incidence of dyslipidemia, as compared to patients with LAD occlusion and classical STEMI on ECG.
de Winter et al. purposed that an anatomical variant of Purkinje fibers with an endocardial conduction delay may be responsible for the ECG changes. They also hypothesized that the absence of ST elevation could be related to lack of activation of sarcolemmal ATP-sensitive potassium channels (KATP) by ischemic ATP depletion as shown in KATP knock-out animal models of acute ischemia. Verouden et al. hypothesized that patients with such pattern have a very extensive transmural ischemic area of infarction that generates only little current which is not sufficient to travel toward the precordial leads but can go toward the lead aVR. The exact mechanism of evolution of this pattern is still a matter of debate.[3],[4]
Although de Winter pattern is being recognized as a STEMI equivalent by majority,[4] since most of the cases were associated with acute LAD occlusion and required emergent reperfusion therapy with fibrinolysis or a primary percutaneous coronary intervention (PCI). However, the 2013 American College of Cardiology Foundation/American Heart Association updated guidelines for the diagnosis and management of STEMI do not recommend fibrinolysis/thrombolysis in such cases.[5] Its quite expected as thrombolysis holds a contradiction in non-STEMI (NSTEMI) cases and the emerging reports on the subject have used PCI for management.[6] However, the case in hand suggests that STK can be used in limited resources with good results.
| Conclusion | | |
Estimated to be present in about 2% of patients with acute anterior wall myocardial infarction; de Winter syndrome, a condition associated with typical chest pain and a characteristic ECG pattern without classic ST-segment elevation; indicates acute total occlusion of the proximal LAD. Partly due to its rarity and partly by its conspicuous absence from the standard texts of medicine and ECG such as Braunwald, Harrisons, API, Schamroth, and Goldberger, it is still under-recognized by clinicians. Not surprisingly, we might be losing some precious lives due to ignorance. Second, now widely believed to be a STEMI equivalent, the treatment of this NSTEMI pattern with thrombolytic agents is a matter of dispute with no clear guidelines. This case is aimed to create awareness about the de Winters pattern and to provide some inputs about the usage of thrombolytics in its management. In a poor country like India, where cath laboratories are absent even at tertiary health centers, the positive outcome and guidelines could prove immense.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA, Interventional Cardiology Group of the Academic Medical Center. A new ECG sign of proximal LAD occlusion. N Engl J Med 2008;359:2071-3.  |
| 2. | Verouden NJ, Koch KT, Peters RJ, Henriques JP, Baan J, van der Schaaf RJ, et al. Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion. Heart 2009;95:1701-6. [ PUBMED] |
| 3. | Goebel M, Bledsoe J, Orford JL, Mattu A, Brady WJ. A new ST-segment elevation myocardial infarction equivalent pattern? Prominent T wave and J-point depression in the precordial leads associated with ST-segment elevation in lead aVr. Am J Emerg Med 2014;32:287.e5-8. |
| 4. | Baranchuk A, Bayés-Genis A. Naming and classifying old and new ECG phenomena. CMAJ 2016;188:485-6. |
| 5. | American College of Emergency Physicians, Society for Cardiovascular Angiography and Interventions, O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr., et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:e78-140. |
| 6. | Goyal KK, Rajasekharan S, Muneer K, Sajeev CG. De Winter sign: A masquerading electrocardiogram in ST-elevation myocardial infarction. Heart India 2017;5:48-50. [Full text] |
[Figure 1], [Figure 2], [Figure 3]
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