Atypical high-risk presentation of the de Winter electrocardiographic pattern
Keywords:
acute coronary syndrome, left coronary artery, non-ST elevated myocardial infarction, unstable anginaAbstract
Introduction: The de Winter electrocardiographic pattern, described in 2008, is associated with proximal occlusion of the left anterior descending artery and is considered a high-risk equivalent of non-ST-segment elevation acute coronary syndrome. It is characterized by upsloping ST-segment depression in the precordial leads (V1–V6), along with tall and symmetrical T waves.
Objective: To describe the electrocardiographic features of this pattern, emphasizing its diagnostic recognition as a high-risk presentation.
Case report: We present the case of a 55-year-old male patient with typical angina whose electrocardiogram showed J-point depression in leads V3–V5, hyperacute T waves, and ST elevation in lead aVR. Coronary angiography revealed severe stenosis of the left anterior descending artery, successfully treated with stent angioplasty.
Conclusions: The de Winter pattern is an atypical electrocardiographic finding indicative of proximal left anterior descending artery occlusion. It constitutes a high-risk presentation that requires early recognition to enable timely reperfusion, even in the absence of classic ST-segment elevation.
Downloads
References
1. Khan MA, Hashim MJ, Mustafa H, Baniyas MY, Suwaidi SKBMA, AlKatheeri R, et al. Global Epidemiology of Ischemic Heart Disease: Results from the Global Burden of Disease Study [Internet]. Cureus. 2020; 12(7):e9349. DOI: 10.7759/cureus.9349
2. Organización Mundial de la Salud. Enfermedad pulmonar obstructiva crónica (EPOC) [Internet]. 2021. [acceso: 27/06/2025]. Disponible en: https://www.who.int/es/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)
3. Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, et al. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST [Internet]. Revista Española de Cardiología. 2021; 74(6):544.e1-544.e73. DOI: 10.1093/eurheartj/ehad191
4. Barthélémy O, Jobs A, Meliga E, Mueller C, Rutten FH, Siontis GCM, et al. Questions and answers on workup diagnosis and risk stratification: a companion document of the 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation [Internet]. Eur Heart J. 2021; 42(14):1379-86. DOI: 10.1093/eurheartj/ehaa602
5. de la Torre Fonseca LM, Pérez Fernández A, Echavarría Sifontes L, Mederos Hernández J, Rojas-Zayas JM, Machín-Legón M, et al. Patrón de «de Winter» en paciente con síndrome coronario agudo sin elevación del segmento ST [Internet]. CorSalud. 2019 [acceso: 27/06/2025]; 11(4):332-6. Disponible en: https://revcorsalud.sld.cu/index.php/cors/article/view/409
6. Qayyum H, Hemaya S, Squires J, Adam Z. Recognising the de Winter ECG pattern - A time critical electrocardiographic diagnosis in the Emergency Department [Internet]. J Electrocardiol. 2018; 51(3):392-5. DOI: 10.1016/j.jelectrocard.2018.03.002
7. Mandal A. De Winter Pattern: Anterior St-Elevation Myocardial Infarction Equivalent [Internet]. ClinicSearch. 2023; 2(5):1-6. DOI: 10.31579/2835-7957/037
8. Wang H, Dai XC, Zhao YT, Cheng XH. Evolutionary de Winter pattern: from de Winter ECG to STEMI-A case report [Internet]. BMC Cardiovasc Disord. 2020; 20(1):324. DOI: 10.1186/s12872-020-01611-0
9. Prasad RM, Al-abcha A, Elshafie A, Radwan YA, Baloch ZQ, Abela GS. The rare presentation of the de Winter’s pattern: Case report and literature review [Internet]. American Heart Journal Plus: Cardiology Research and Practice. 2021; 3:100013. DOI: 10.1016/j.ahjo.2021.100013
10. Huang W, Mai L, Lu J, Li W, Huang Y, Hu Y. Evolutionary de Winter pattern: from STEMI to de Winter ECG—a case report [Internet]. ESC Heart Failure. 2022; 9(1):771-4. DOI: 10.1002/ehf2.13711
11. Burelo-López G, Hernández-Valerio R, Chagoya-Triana M, Ixta-Rojas F, Cano-Nigenda V, Burelo-López G, et al. The «de Winter» pattern as equivalent of acute ST segment elevation myocardial infarction [Internet]. Cardiovascular and metabolic science. 2020; 31(2):49-52. DOI: 10.35366/94773
12. Wang J, Diao S, Ma B. Dynamic evolvement of the de Winter ECG pattern [Internet]. Annals of Noninvasive Electrocardiology. 2021; 26(5):e12881. DOI: 10.1111/anec.12881
13. Tiyantara MS, Herdianto D. The de Winter Pattern as Pre-Anterior ST-Elevation-Myocardial-Infarction. “An Evolution Sequence”: A Case Report [Internet]. Indonesian Journal of Cardiology. 2021 [acceso 29/06/25]; 42(2):e1126. Disponible en: https://ijconline.id/index.php/ijc/article/view/1126
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Luis Mariano de la Torre Fonseca, Jean Carlos Marcillo Marcillo, Luis Felipe Oviedo Vasquez, Diego Geovanny Delgado Intriago, Ronald Eduardo Pucha Pesántez, Rubén Andrés Guamán Castro
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Authors who have publications with this Journal accept the following terms:
- The authors will retain their copyright and guarantee the Journal the right of first publication of their work, which will simultaneously be subject to the Creative Commons Attribution License. The content presented here can be shared, copied and redistributed in any medium or format; Can be adapted, remixed, transformed or created from the material, using the following terms: Attribution (giving appropriate credit to the work, providing a link to the license, and indicating if changes have been made); non-commercial (you cannot use the material for commercial purposes) and share-alike (if you remix, transform or create new material from this work, you can distribute your contribution as long as you use the same license as the original work).
- The authors may adopt other non-exclusive license agreements for the distribution of the published version of the work (for example: depositing it in an institutional electronic archive or publishing it in a monographic volume) as long as the initial publication in this Journal is indicated.
- Authors are allowed and recommended to disseminate their work through the Internet (e.g., in institutional electronic archives or on their website) before and during the submission process, which can produce interesting exchanges and increase citations. of the published work.
