CASE REPORT

Total occlusion of coronary artery without ST-segment elevation a case series of ‘de Winter’ electrocardiogram pattern

Destrian Ekoputro Wismiyarso, Carina Adriana, Arjatya Pramadita Mangkoesoebroto, Arman Christiawan, Aldila Nila Sulma, Lita Hati Dwi Purnami Effendi, Pipin Ardhianto

Destrian Ekoputro Wismiyarso
Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia

Carina Adriana
Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia

Arjatya Pramadita Mangkoesoebroto
Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia

Arman Christiawan
Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia

Aldila Nila Sulma
Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia

Lita Hati Dwi Purnami Effendi
Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia

Pipin Ardhianto
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Diponegoro– Dr. Kariadi Central General Hospital Semarang, Indonesia. Email: [email protected]
Online First: April 30, 2021 | Cite this Article
Wismiyarso, D., Adriana, C., Mangkoesoebroto, A., Christiawan, A., Sulma, A., Effendi, L., Ardhianto, P. 2021. Total occlusion of coronary artery without ST-segment elevation a case series of ‘de Winter’ electrocardiogram pattern. Bali Medical Journal 10(1): 347-350. DOI:10.15562/bmj.v10i1.2166


Background: A ‘STEMI equivalent’ electrocardiogram (ECG) pattern describes an acute thrombotic occlusion of a large coronary artery without ST-segment elevation. This pattern must be recognized and treated with emergent reperfusion therapy. De Winter syndrome is a special ECG pattern reflecting acute occlusion in the proximal segment of LAD (left anterior descending) coronary artery and a primary percutaneous coronary intervention (PCI) should be performed as early as possible.

Case illustration: We present two patients admitted to the emergency department with symptoms of chest pain. Their ECGs revealed de-Winter T waves and then coronary angiography was performed. Total occlusion in the proximal segment of the LAD coronary artery was observed in both patients, and stents were implanted to the culprit lesion. Both ECG patients show an up-sloping ST-segment depression (STD, >1 mm) starting from the J-point, with symmetrical, tall and significant T-waves in the precordial leads. This ECG pattern indicates a LAD coronary artery obstruction. The ‘de Winter’ ECG pattern is not mentioned in the ESC guidelines, but it is essential to recognize this rare ECG pattern as the STEMI equivalent, and it must be treated with prompt revascularization therapy.

Conclusion: The ‘de Winter’ ECG pattern, as other ‘STEMI equivalent’, must be recognized promptly and treated as soon as possible with emergent reperfusion by percutaneous coronary intervention.

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