Author + information
- Anne-Flore Plane, MDa,∗ (, )
- Xavier Valette, MDb,
- Katrien Blanchart, MDa,
- Pierre Ardouin, MDa,
- Farzin Beygui, MD, PhDa,c and
- Vincent Roule, MDa,c
- aDepartment of Cardiology, Caen University Hospital, Caen, France
- bDepartment of Medical Intensive Care, Caen University Hospital, Caen, France
- cUniversity of Normandy, UNICAEN, EA 4650 Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, Caen, France
- ↵∗Address for correspondence:
Dr. Anne-Flore Plane, Department of Cardiology, Caen University Hospital, Avenue Cote de Nacre, 14033 Caen, France.
This report describes the case of a 48-year-old man whose electrocardiogram after cardiopulmonary resuscitation showed up-sloping ST-segment depression at the J point in precordial leads combined with tall symmetrical T waves. This electrocardiographic pattern corresponded to de Winter syndrome and is related to proximal left anterior descending coronary artery occlusion. (Level of Difficulty: Beginner.)
A 48-year-old man with a history of dyslipidemia and hypertension was admitted after an out-of-hospital cardiac arrest secondary to ventricular fibrillation. He recovered after cardiopulmonary resuscitation and defibrillation with 3 electric shocks. Thereafter, he was hemodynamically stable but reported chest pain. The electrocardiogram performed in the ambulance showed ST-segment depression at the J point in the precordial leads combined with tall symmetrical T waves (Figure 1A). There was also ST-segment depression in the inferior leads and slight ST-segment elevation in lead aVR. He presented initially sinus bradycardia that resolved spontaneously, but other electrocardiographic (ECG) changes remained stable 30 min later (Figure 1B).
What is the most likely diagnosis?
1. Coronary occlusion is unlikely because ECG changes remain stable.
2. The ECG patterns are suggestive of left anterior descending coronary artery (LAD) occlusion.
3. These findings correspond to early repolarization.
4. The patient has severe hyperkalemia.
The correct answer is option 2. Indeed, this typical ECG pattern with up-sloping ST-segment depression at the J point in the precordial leads (black arrows) followed by tall, positive symmetrical T waves (black stars) corresponds to de Winter syndrome (Supplemental Figures 1A and 1B). This syndrome is related to proximal LAD occlusion (1). A slight ST-segment elevation in lead aVR is often present. Contrary to early hyperacute T waves that progress rapidly into a classical ST-segment elevation myocardial infarction pattern, the ECG changes are usually static until coronary reperfusion in this syndrome (2). The QRS complexes are not widened, and tall T waves are seen only in the precordial leads, unlike the ECG pattern in hyperkalemia. Early repolarization could have been evoked because it was associated with an increased risk of ventricular fibrillation. Although variable, its pattern includes ST-segment elevation and terminal QRS complex slurring or notching, and its arrhythmogenic form usually involves tall J waves with limited ST-segment elevation in the inferior leads, contrary to our case (3).
De Winter syndrome is reported in 2% of patients with anterior myocardial infarction. In our patient, urgent coronary angiography showed thrombotic occlusion of the proximal LAD that was successfully treated with thrombus aspiration and deferred coronary bypass (Video 1). The electrophysiological explanation remains elusive, but this syndrome could be secondary to the very large area of transmural ischemia or an anatomic variant of Purkinje fibers with an endocardial conduction delay. It is important to recognize this syndrome to ensure timely reperfusion therapy. Indeed, despite the absence of ST-segment elevation, de Winter syndrome is considered to be an ST-segment elevation myocardial infarction equivalent for some cardiologists, and its recognition is necessary for appropriate cardiac catheterization laboratory activation (4). The infarct size is usually large, as outlined by the Q waves in leads V1 to V3 at day 1 in our patient despite adequate reperfusion.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- left anterior descending coronary artery
- Received May 1, 2019.
- Revision received August 19, 2019.
- Accepted September 13, 2019.
- 2019 The Authors
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