de Winter syndrome

de Winter syndrome

de Winter syndrome was initially described as a new ECG sign of occlusion of proximal left anterior descending (LAD) coronary artery by Robbert J de Winter, Niels J W Verouden, Hein J J Wellens and Arthur A M Wilde, Interventional Cardiology Group of the Academic Medical Center, in 2008 as a Letter to the Editor [1]. Instead of the ST segment elevation which is typical of anterior wall infarction which occurs in total occlusion of LAD, they described anterior ST segment depression, in about 2% of cases.

An ECG with typical features showing upsloping ST segment depression in anterior leads with tall symmetric T waves and loss of precordial R wave progression reported by Pedro Martínez-Losas and Rodrigo Fernández-Jiménez is available at Pubmed Central (Free Full Text) [2]. Their patient underwent angioplasty with drug eluting stent.

Thus de Winter syndrome can be considered as a STEMI (ST elevation myocardial infarction) equivalent [3]. Early recognition and prompt management by revascularization is desirable. 

Yang-Yi Lin, Yu-Dan Wen, Guo-Lin Wu, and Xiang-Dong Xu have documented the same patient can have evolution of ECG changes between that of de Winter syndrome and STEMI. They demonstrated this in two cases [4].

Though initially described for anterior leads and LAD occlusion, other authors have extended the findings to other leads and coronary territories. Katsuhiko Tsutsumi and Kengo Tsukahara demonstrated ST segment depression from the J point, continuing as symmetrical positive T waves in inferior and lateral leads, published in Circulation. Coronary angiography showed acute total occlusion of right coronary artery for which angioplasty and stent implantation was done [5].

In another report by Murat Sunbul, Okan Erdogan, Osman Yesildag and Bulent Mutlu,  ST segment elevations in leads aVR, aVL, V1 and V2 and ST segment depressions in leads II, III, aVF and V 3–6 at the J point was associated with total occlusion of left main coronary artery [6].

References

  1. Robbert J de Winter, Niels J W Verouden, Hein J J Wellens, Arthur A M Wilde, Interventional Cardiology Group of the Academic Medical Center. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008 Nov 6;359(19):2071-3.
  2. Pedro Martínez-Losas, Rodrigo Fernández-Jiménez. de Winter syndrome. CMAJ. 2016 Apr 19;188(7):528. 
  3. Kunal Mahajan, Aditya Batra, Abhishek Gupta. de Winter sign-A STEMI Equivalent. Indian Heart J. Sep-Oct 2018;70(5):761-764.
  4. Yang-Yi Lin, Yu-Dan Wen, Guo-Lin Wu, Xiang-Dong Xu. De Winter syndrome and ST-segment elevation myocardial infarction can evolve into one another: Report of two cases. World J Clin Cases. 2019 Oct 26;7(20):3296-3302.
  5. Katsuhiko Tsutsumi 1, Kengo Tsukahara. Is The Diagnosis ST-Segment Elevation or Non-ST-Segment Elevation Myocardial Infarction? Circulation. 2018 Dec 4;138(23):2715-2717.
  6. Murat Sunbul, Okan Erdogan, Osman Yesildag, Bulent Mutlu. De Winter sign in a patient with left main coronary artery occlusion. Postepy Kardiol Interwencyjnej. 2015;11(3):239-40.