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Heliyon
Heliyon
Heliyon
2405-8440
Elsevier

S2405-8440(24)13166-0
10.1016/j.heliyon.2024.e37135
e37135
Case Report
The de Winter pattern in a single precordial lead caused by high-grade stenosis of the proximal left anterior descending artery with plaque rupture: A case report
Song Zhizhou a
Huo Yuehong b
Wu Qi a
Yu Xinjian c
Yang Youdong a
Meng Zejun a
Li Xia lixia@sxtcm.edu.cn
de⁎
a Department of Cardiology, The Third People's Hospital of Datong, Datong, Shanxi 037046, China
b Department of Rheumatology, The Fifth People's Hospital of Datong, Datong, Shanxi 038300, China
c Quantitative and Computational Biosciences Graduate Program, Baylor College of Medicine, Houston, TX 77030, USA
d The Third Clinical College, Shanxi University of Chinese Medicine, Taiyuan, Shanxi 030024, China
e Clinical Research Center, The Third People's Hospital of Datong, Datong, Shanxi 037046, China
⁎ Corresponding author. The Third Clinical College, Shanxi University of Chinese Medicine, Taiyuan, Shanxi 030024, China. lixia@sxtcm.edu.cn
04 9 2024
15 9 2024
04 9 2024
10 17 e3713512 1 2024
22 8 2024
28 8 2024
© 2024 The Authors. Published by Elsevier Ltd.
2024

https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
The de Winter electrocardiogram (ECG) pattern indicates severe stenosis or occlusion of the left anterior descending artery (LAD). We present a 72-year-old female with 1.5-h chest pain. Angiography and optical coherence tomography (OCT) revealed 90 % LAD stenosis with plaque rupture, but no ST-segment elevation in the precordial leads. The de Winter pattern, characterized by upsloping ST-segment depression in V1-V6, appeared only in lead V2. Following successful percutaneous coronary intervention (PCI), the de Winter pattern disappeared. This case underscores the significance of the de Winter pattern in one precordial lead, necessitating prompt angiography and PCI for improved patient outcomes.

Keywords

De winter pattern
Coronary artery disease
Acute coronary syndrome
Left anterior descending artery
Percutaneous coronary intervention
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pmc1 Introduction

In acute anterior myocardial infarction caused by severe stenosis or complete occlusion of the proximal left anterior descending artery (LAD), approximately 2 % of patients do not exhibit ST-segment elevation on the electrocardiogram (ECG) but rather show the de Winter pattern [1], which was first described by de Winter et al., in 2008 [2]. The typical de Winter ECG pattern include: (1) an upsloping ST-segment depression of 1–3mm at the J point in the precordial leads, followed by tall, positive symmetrical T-waves; (2) usually not widened or only slightly widened QRS complexes; (3) poor R wave progression in precordial leads in some cases; (4) mild ST-segment elevation in lead aVR in most cases. For patients presenting with de Winter ECG pattern, prompt invasive coronary angiography should be performed, similar to cases with ST-segment elevation myocardial infarction (STEMI). If necessary, coronary catheterization and percutaneous coronary intervention (PCI) should be initiated to reduce mortality [3]. The de Winter ECG pattern in a single precordial lead caused by severe LAD stenosis or occlusion has not been previously reported in the literature. Here, we report the case of a patient with chest pain whose ECG exhibited upsloping ST-segment depression only in lead V2, while coronary angiography suggested high-grade stenosis of the LAD with plaque rupture.

2 Case report

A 72-year-old female presented to the emergency department on September 14, 2022, with the chief complaint of chest pain. Prior to admission, the patient experienced sudden squeezing chest pain in the precordial area lasting for 1.5 hours while at rest, accompanied by left back pain, sweating, dizziness, and nausea. The ECG showed sinus rhythm, ST-segment depression of 0.05mV in leads II and aVF, T-wave inversion in lead III, rS pattern in leads V1-V6, J-point depression and upsloping ST-segment depression with a tall, peaked T-wave in lead V2, flat T-waves in leads V3-V6, and ST-segment elevation of 0.1mV in lead aVR (Fig. 1). Cardiac enzyme tests showed a troponin I (cTnI) level of 0.3 ng/mL, a creatine kinase-MB (CK-MB) level of 3.23 ng/mL, and a myoglobin (Myo) level of 38 ng/mL. Physical examination showed a blood pressure of 127/80 mmHg, a heart rate of 75 beats per minute with a normal cardiac rhythm, and no murmurs were heard across all valve areas. Bilateral lung auscultation revealed clear sounds without rales or rhonchi. The patient had a history of hypertension for 7 years, with the highest blood pressure recorded at 160/95 mmHg. She was currently taking amlodipine besylate at a daily dose of 2.5mg and maintained the blood pressure around 140/85 mmHg. Six months prior to admission, the patient underwent radical cystectomy for bladder cancer and had a full recovery without further postoperative chemotherapy or radiation therapy. No history of smoking or alcohol consumption was reported.Fig. 1 ECG showed sinus rhythm, ST-segment depression of 0.05mV in lead II and aVF, T-wave inversion in lead III, rS pattern in leads V1-V6, J-point depression and upsloping ST-segment depression with tall, peaked T-waves in lead V2, flat T-waves in leads V3-V6, and ST-segment elevation of 0.1mV in lead aVR.

Fig. 1

The patient was diagnosed with coronary artery disease (CAD), acute non-ST-segment elevation myocardial infarction (NSTEMI, Killip class I) with a GRACE score of 191, stage 2 hypertension (considered at the highest risk for cardiovascular events), and postoperative bladder cancer. The patient was administered aspirin and clopidogrel, each at a dose of 300mg, followed by emergency coronary angiography. Severe diffuse stenosis was observed in the proximal to mid segment of the LAD (90 % stenosis of the proximal LAD), as well as a 70 % stenosis in the proximal circumflex artery (Supplementary Video S1-S5). Given the significant tightness of the proximal LAD lesion, we performed a 2.0*15mm balloon pre-dilatation before OCT imaging. No significant stenosis was present in the right coronary artery (Fig. 2D–F). Optical coherence tomography (OCT) revealed an intimal tear, dissection, white thrombus, and mixed thrombus (Fig. 2A–C). These findings indicated that acute myocardial infarction (AMI) event was caused by plaque rupture on the basis of high-grade stenosis in the proximal LAD. Stents (2.25mm/29mm and 2.5mm/20mm) were implanted in the proximal to mid segment of the LAD (Fig. 2G–Supplementary Video S6). The postoperative OCT showed good stent apposition and complete coverage of the dissection. The patient was prescribed enteric-coated aspirin and clopidogrel to inhibit platelet aggregation, rosuvastatin calcium tablets to regulate blood lipids and stabilize the plaque, and metoprolol to reduce myocardial oxygen consumption. The patient's condition remained stable after treatment. Since discharge, no angina has been reported (Fig. 3).Fig. 2 OCT revealed an intimal tear, dissection, white thrombus, and mixed thrombus. (A–C) showed mixed thrombus (red arrow), white thrombi (white arrows), intimal tear (green arrows), and dissection (asterisks). Coronary angiography revealed: (D) severe diffuse stenosis in the proximal to mid segment of the LAD with plaque rupture (90 % stenosis of the proximal LAD); (E) 70 % stenosis in the proximal circumflex artery; (F) scattered plaques in the right coronary artery; (G) stent implantation in the LAD.

Fig. 2

Fig. 3 Timeline of the diagnosis and treatment procedures.

Fig. 3

3 Discussion

In this case, the patient's emergency ECG exhibited an upsloping ST-segment depression in precordial lead V2, accompanied by tall, peaked, and symmetrical T-waves. Additionally, there was a mild ST-segment elevation in lead aVR and poor R wave progression in precordial leads. The ECG pattern in lead V2 resembled the de Winter pattern, but overall, it also significantly deviated from the classical de Winter pattern. According to the Fourth Universal Definition of Myocardial Infarction [4], the de Winter pattern is considered one of the atypical ECG manifestations in acute coronary syndrome (ACS) caused by occlusion of the proximal LAD. Specifically in such cases, coronary angiography often suggests occlusion or severe stenosis in the proximal LAD, but the ECG does not exhibit the ST-segment elevation typically seen in STEMI or its hyperacute phase. Currently, there is no further classification for this atypical ACS internationally or domestically. The main reasons are as follows: (1) It cannot be classified as NSTEMI because of different pathogenesis. Although the ECG suggests upsloping ST-segment depression, angiography often confirms complete or subtotal occlusion in the proximal LAD. Emergency PCI is required to restore blood flow and relieve symptoms. (2) Before PCI, the ST-segment elevation is not present in most cases. Therefore, according to its definition, these cases cannot be classified as STEMI either.

The international and domestic community has been refining clinical guidelines to provide optimal treatment for patients with the de Winter pattern. The European Society of Cardiology recommends in the STEMI management guidelines that for patients with ongoing myocardial ischemia but atypical ECG presentations, PCI is the preferred strategy [5]. Furthermore, the 2019 Chinese guidelines for the diagnosis and treatment of acute STEMI state that de Winter pattern should be considered an equivalent ECG change to STEMI [6]. Despite its lower incidence, the short-term prognosis for patients with de Winter syndrome is no better than that for patients with anterior wall myocardial infarction. There have been reports of emergency electrocardiograms exhibiting de Winter patterns, with emergency angiography indicating occlusion of the first diagonal branch [7]. Studies have confirmed that patients with de Winter syndrome may present with dynamic ST-T changes in precordial leads, which may potentially progress to anterior wall STEMI [8,9]. Currently, the presence of de Winter patterns on the electrocardiograms of patients with acute chest pain is not an indication for thrombolysis, nor is there definitive evidence of acute coronary artery occlusion [10].

All healthcare professionals, especially those in chest pain centers, should be aware that once patients present with the de Winter ECG pattern, emergency PCI should be performed as soon as possible to reduce mortality rates and improve prognosis.

In this case, the patient's ECG exhibited de Winter pattern only in lead V2. However, the diagnosis NSTEMI based on the symptoms, physical examinations, and laboratory tests. The underlying pathological bases primarily include acute thrombus formation caused by high-grade coronary artery stenosis and/or vulnerable plaque rupture or erosion, with or without vasoconstriction and microvascular embolization, leading to reduced coronary blood flow and myocardial ischemia. The patient was stratified as high risk according to the GRACE score. According to the guidelines [11], we performed early invasive strategies for this patient within 24 hours. The angiography indicated severe diffuse stenosis in the proximal to mid segment of the LAD, with the most severe stenosis of 90 % in the proximal LAD. Meanwhile, OCT confirmed an acute myocardial ischemic event caused by vulnerable plaque rupture in the proximal to mid segment of the LAD on the basis of high-grade stenosis. After stent implantation, the stenosis was resolved, and the chest pain was relieved. Postoperative echocardiography showed reduced wall motion in the middle to apical segment of the left ventricular anterior wall, decreased left ventricular systolic and diastolic function, and an ejection fraction of 43 %. Postoperative ECG revealed myocardial infarction-like changes in the anterior leads and changes resembling Wellens syndrome on the second and third day (Fig. 4). Currently no literature has reported the de Winter pattern in a single precordial lead. The mechanisms underlying the de Winter ECG pattern only in lead V2 still remain unclear. In cases where the ST segment in the anterior leads exhibits an upsloping depression rather than elevation in the de Winter ECG pattern, it may be attributed to an extensive ischemic area in the anterior wall [12], which fails to generate an injury current towards the precordial leads and instead directs it towards aVR. This patient might also exhibit heterogeneity in myocardial ischemic tolerance across different regions of the anterior wall or possess anatomical variations in the left ventricular endocardial Purkinje fibers, leading to endocardial conduction disturbances. Consequently, these factors could result in an isolated upsloping depression in lead V2, while the other precordial leads display poor R-wave progression, a phenomenon that resolves following interventional treatment.Fig. 4 Postoperative and in-hospital ECG. On September 14, the postoperative ECG showed the disappearance of the de Winter pattern in lead V2, and bidirectional T-waves in leads V3-V6. On September 14 and 16, the ECG showed inverted T-waves in leads V2-V6, consistent with Wellens syndrome. On September 18, the ECG showed bidirectional T-waves in leads V2-V6. On September 19, the ECG showed bidirectional or upright T-waves in leads V2-V6.

Fig. 4

This case highlights the importance of the de Winter pattern in a single precordial lead in addition to the classical de Winter pattern, as it may represent a more unique type of ACS. It also reminds us to identify high-risk patients as early as possible, strive for timely reperfusion therapy to salvage more myocardium, and prevent the potential life-threatening consequences due to disease progression.

4 Ethics statement

This study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the patients for the publication of any identifiable images or data included in this article.

Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article.

CRediT authorship contribution statement

Zhizhou Song: Writing – original draft. Yuehong Huo: Formal analysis. Qi Wu: Writing – review & editing. Xinjian Yu: Data curation. Youdong Yang: Data curation. Zejun Meng: Writing – review & editing. Xia Li: Writing – review & editing.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work the authors used ChatGPT in order to improve language. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Abbreviation

electrocardiogram ECG

left anterior descending artery LAD

optical coherence tomography OCT

percutaneous coronary intervention PCI

ST-segment elevation myocardial infarction STEMI

acute non-ST-segment elevation myocardial infarction NSTEMI

coronary artery disease CAD

acute myocardial infarction AMI

creatine kinase-MB CK-MB

Myoglobin Myo

Appendix A Supplementary data

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Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.heliyon.2024.e37135.
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