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Impending anterior myocardial infarction: de Winter syndrome
American Journal of Emergency Medicine xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence
Impending anterior myocardial infarction: de Winter syndrome☆ To the Editor, It is commonly known that de Winter syndrome is a lesion of the left anterior descending coronary artery (LAD) that carries a substantial risk of developing into acute anterior wall myocardial infarction. A key diagnostic feature of this syndrome is the altered T wave in an electrocardiogram (ECG). This report presents a case of de Winter syndrome and the associated ECG pattern. A 63-year-old man with type 2 diabetes presented with complaints of severe precordial chest pain with stuffiness and chest distress after an activity 3 hours before; the chest pain remitted after ½ hours. The ECG (Fig. 1) showed a J-point depression, upsloping ST segments, and symmetrical T waves in leads V2 though V5. Laboratory examinations were as follows: troponin I, 0.06 (0-0.1) ng/mL; Myo, 44.4 (17.4105.7) ng/mL; creatine kinase–MB, 2.3 (0.3-6.3) ng/mL; and brain natriuretic peptide, 43 (0-100) pg/mL. These ECG changes suggested de Winter syndrome, a condition associated with acute occlusion of the LAD, with no ST-segment elevation [1]. Urgent coronary angiography identified a critical 95% fixed stenosis of the mid-LAD just after the first diagonal artery, which was successfully treated with angioplasty and a drug-eluting stent (Fig. 2). In 2008, de Winter and colleagues [1] described a novel ECG pattern, with “1 to 3 mm upsloping ST-segment depression at the J-point in leads V1 to V6 that continue into tall, positive symmetrical T-waves” and “1 to 2 mm ST- segment elevation in lead aVR” [2]. However, this finding is rare, occurring in approximately 2% of patients with LAD occlusion [2]. In this case, the ECG (Fig. 1) clearly shows the tall, symmetrical T wave and upsloping ST-segment depression of the de Winter pattern, but without ST-segment elevation in aVR.
De Winter syndrome is a condition typically associated with chest pain and a characteristic ECG pattern without a classic ST-segment elevation, yet acute subtotal occlusion of the LAD. This syndrome, estimated to be present in only 2% of patients with acute anterior myocardial infarction [2], is currently underrecognized by clinicians, and, hence, is associated with increased morbidity and mortality. This case highlights the need for the timely identification of this aberrant ECG pattern and the appropriate move to urgent coronary arteriography for possible angioplasty. Recognition of this ECG pattern by ambulance staff, emergency physicians, and interventional cardiologists involved in ST-elevation myocardial infarction networks is important to ensure timely reperfusion therapy for these patients. Yun-Tao Zhao MD, PhD* Chen Chia-Chen MD Department of Cardiology, Aerospace Center Hospital, Beijing, PR China *Corresponding author at: Department of Cardiology, Aerospace Center Hospital, 15 Yuquan Rd, Haidian District, Beijing 100049, PR China Tel.: +86 10 59971314 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2016.09.019 References [1] de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA, Interventional Cardiology Group of the Academic Medical C.. A new ECG sign of proximal LAD occlusion. N Engl J Med 2008;359(19):2071–3. [2] Verouden NJ, Koch KT, Peters RJ, Henriques JP, Baan J, van der Schaaf RJ, et al. Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion. Heart 2009;95(20):1701–6.
☆ There are no conflicts of interest. 0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Zhao Y-T, Chia-Chen C, Impending anterior myocardial infarction: de Winter syndrome, Am J Emerg Med (2016), http:// dx.doi.org/10.1016/j.ajem.2016.09.019
2
Correspondence / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Fig. 1. Electrocardiogram showing 1- to 3-mm upsloping ST-segment depression in the V2 through V5 leads.
Fig. 2. Cardiac catheterization showing the middle LAD before (left) and after (right) stent placement.
Please cite this article as: Zhao Y-T, Chia-Chen C, Impending anterior myocardial infarction: de Winter syndrome, Am J Emerg Med (2016), http:// dx.doi.org/10.1016/j.ajem.2016.09.019
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence
Impending anterior myocardial infarction: de Winter syndrome☆ To the Editor, It is commonly known that de Winter syndrome is a lesion of the left anterior descending coronary artery (LAD) that carries a substantial risk of developing into acute anterior wall myocardial infarction. A key diagnostic feature of this syndrome is the altered T wave in an electrocardiogram (ECG). This report presents a case of de Winter syndrome and the associated ECG pattern. A 63-year-old man with type 2 diabetes presented with complaints of severe precordial chest pain with stuffiness and chest distress after an activity 3 hours before; the chest pain remitted after ½ hours. The ECG (Fig. 1) showed a J-point depression, upsloping ST segments, and symmetrical T waves in leads V2 though V5. Laboratory examinations were as follows: troponin I, 0.06 (0-0.1) ng/mL; Myo, 44.4 (17.4105.7) ng/mL; creatine kinase–MB, 2.3 (0.3-6.3) ng/mL; and brain natriuretic peptide, 43 (0-100) pg/mL. These ECG changes suggested de Winter syndrome, a condition associated with acute occlusion of the LAD, with no ST-segment elevation [1]. Urgent coronary angiography identified a critical 95% fixed stenosis of the mid-LAD just after the first diagonal artery, which was successfully treated with angioplasty and a drug-eluting stent (Fig. 2). In 2008, de Winter and colleagues [1] described a novel ECG pattern, with “1 to 3 mm upsloping ST-segment depression at the J-point in leads V1 to V6 that continue into tall, positive symmetrical T-waves” and “1 to 2 mm ST- segment elevation in lead aVR” [2]. However, this finding is rare, occurring in approximately 2% of patients with LAD occlusion [2]. In this case, the ECG (Fig. 1) clearly shows the tall, symmetrical T wave and upsloping ST-segment depression of the de Winter pattern, but without ST-segment elevation in aVR.
De Winter syndrome is a condition typically associated with chest pain and a characteristic ECG pattern without a classic ST-segment elevation, yet acute subtotal occlusion of the LAD. This syndrome, estimated to be present in only 2% of patients with acute anterior myocardial infarction [2], is currently underrecognized by clinicians, and, hence, is associated with increased morbidity and mortality. This case highlights the need for the timely identification of this aberrant ECG pattern and the appropriate move to urgent coronary arteriography for possible angioplasty. Recognition of this ECG pattern by ambulance staff, emergency physicians, and interventional cardiologists involved in ST-elevation myocardial infarction networks is important to ensure timely reperfusion therapy for these patients. Yun-Tao Zhao MD, PhD* Chen Chia-Chen MD Department of Cardiology, Aerospace Center Hospital, Beijing, PR China *Corresponding author at: Department of Cardiology, Aerospace Center Hospital, 15 Yuquan Rd, Haidian District, Beijing 100049, PR China Tel.: +86 10 59971314 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2016.09.019 References [1] de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA, Interventional Cardiology Group of the Academic Medical C.. A new ECG sign of proximal LAD occlusion. N Engl J Med 2008;359(19):2071–3. [2] Verouden NJ, Koch KT, Peters RJ, Henriques JP, Baan J, van der Schaaf RJ, et al. Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion. Heart 2009;95(20):1701–6.
☆ There are no conflicts of interest. 0735-6757/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Zhao Y-T, Chia-Chen C, Impending anterior myocardial infarction: de Winter syndrome, Am J Emerg Med (2016), http:// dx.doi.org/10.1016/j.ajem.2016.09.019
2
Correspondence / American Journal of Emergency Medicine xxx (2016) xxx–xxx
Fig. 1. Electrocardiogram showing 1- to 3-mm upsloping ST-segment depression in the V2 through V5 leads.
Fig. 2. Cardiac catheterization showing the middle LAD before (left) and after (right) stent placement.
Please cite this article as: Zhao Y-T, Chia-Chen C, Impending anterior myocardial infarction: de Winter syndrome, Am J Emerg Med (2016), http:// dx.doi.org/10.1016/j.ajem.2016.09.019