Medical Case Reports

The De Winter Dilemma: The Management and Outcome of a Patient with De Winter Electrocardiographic Pattern in the Pre-Hospital Setting

De Winter sign, first described by De Winter et al. in 2008, is an electrocardiographic (EKG) pattern associated with typical chest pain without classic ST-segment elevation that signifies total occlusion of the proximal left anterior descending coronary artery (LAD). In this case report we aim to highlight the dilemma of the use of thrombolytic therapy in patients with De Winter EKG pattern in the absence of immediate primary percutaneous coronary intervention (PPCI). A 66-year-old patient encountered the emergency department (ED) of a secondary care hospital for chest pain that began 30 minutes prior to his ED visit with more than 1 mm up-sloping ST depression with symmetric tall T in lead V3-V4-V5 and V6 characteristic of De Winter T-wave ECG pattern. The patient then presented a cardio-respiratory arrest with initial rhythm being read as pulseless ventricular tachycardia. He was resuscitated and received 3 chocks. The resuscitation was successful and EKG showed an ST segment elevation in the precordial leads. Thrombolytic therapy was administered and successful. Angiographic evidence of an occluded LAD was obtained later on. Although De Winter’s pattern was proved to be a sign of critical occlusion of the proximal segment of LAD artery, there lacks proper guidelines on the management of this particular EKG sign. Moreover, thrombolytic therapy is still controversial in the presence of such a sign as current guidelines advocate against this therapy in the absence of STEMI. Our case report adds to the emergent cases of patients with EKG De Winter pattern having significant LAD occlusion that was successfully treated with thrombolytic agents.

Author(s):

Ensaf Missaoui, Ben Cheikh Cherifa, Mahmoudi Ahmed, Mounir Naïja* and Naoufel Chebili

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