The de Winter electrocardiography (ECG) pattern is a sign that implies proximal left anterior descending coronary artery occlusion in patients with chest pain. The previous view was that the de Winter ECG pattern is static.

A 65-year-old man presented with sudden chest pain at rest associated with diaphoresis for 55 min. The first ECG showed only T-wave inversion in III and aVF leads. Another ECG was performed at the 100^th minute, showing upsloping ST segments depressed with tall and symmetrical T waves in the precordial leads; the J point was raised by 0.1 mV at the aVR lead. The patient was referred to our catheterization laboratory. A third ECG showed ST segment elevation by 0.2 mV in the I and aVL leads. The patient underwent emergency coronary angiography, which revealed complete proximal left anterior descending coronary (LAD) occlusion. The second patient presented with a 1-h history of sudden-onset, severe, substernal crushing chest pain. The first ECG showed ST-segment elevation (0.1–1.7 mV) in I, aVL, and precordial leads. The patient was referred to the catheterization laboratory. On arrival, his symptoms alleviated, and ECG showed that the ST-segments had significantly fallen back. The third ECG showed a typical de Winter pattern. Coronary angiography revealed 99% stenosis of the middle LAD.

The de Winter ECG pattern is transient and dynamic, and it reflects proximal or mid-LAD subtotal occlusion rather than total occlusion.

The de Winter electrocardiography (ECG) pattern is a sign that implies proximal left anterior descending coronary artery occlusion in patients with chest pain. The previous view was that the de Winter ECG pattern is static. We show that de Winter and ST-segment elevation myocardial infarction can evolve into one another.

The de Winter ECG pattern (ST-segment upsloping depression and tall, positive symmetrical T waves; ST-elevation (1–2 mm) in lead aVR; a loss of precordial R-wave progression; and QRS complexes not widened or slightly widened) was first described by de Winter in 2008[1]. The key diagnostic features of the de Winter ECG pattern include the follow two points: (A) ST-segment upsloping depression > 1 mm with tall and positive symmetrical T waves in the precordial leads; and (B) ST-segment elevation in the aVR lead[2-4]. The previous view of this ECG pattern was that it is static and indicates complete proximal LAD occlusion[1,4]. However, our two cases demonstrate that the ECG pattern of de Winter syndrome and STEMI can evolve into one another. The first patient evolved from de Winter syndrome to STEMI after 72 min, and coronary angiography revealed complete proximal LAD occlusion. The second patient transformed from STEMI to de Winter syndrome after 2 h, and a 99% middle LAD stenosis was confirmed by coronary angiography. Goebel et al[5] reported a case of de Winter pattern progressing to STEMI within several hours and Lam et al[6] described a patient who spontaneously transformed from STEMI to de Winter pattern before emergency angiography and reperfusion therapy, which are similar to our present cases. Therefore, we believe that the de Winter ECG pattern reflects a coronary thrombus in formation which, however, has not completely occluded the coronary arteries. The ECG pattern of STEMI changes to the de Winter syndrome owing to autolysis of the intracoronary thrombus. Therefore, we believe the de Winter ECG pattern is transient, and either progresses to STEMI when the thrombus continues to form and completely occludes the coronary arteries, or the thrombus autolyzes and the ECG tends to become normal. Zhao et al[7] also showed spontaneous recanalization of the thrombus in a patient with de Winter syndrome. Pica et al[8] reported a case of acute stent thrombosis with de Winter ECG pattern, after thrombectomy and ballooning, the de Winter ECG pattern with typical ECG evolution as STEMI. What’s more, our second patient showed an elevated D-dimer value of 5.14 ug/mL, which reflected autolysis of the intracoronary thrombus. In essence, de Winter syndrome may be a thrombotic disease. The two patients with de Winter syndrome reported by Rao et al[9] and Pranata et al[10], who were treated successfully with thrombolytic therapy, support this opinion.

The de Winter ECG pattern is transient and dynamic, and it reflects proximal or mid-LAD subtotal occlusion rather than total occlusion. Physicians and others who attend patients with chest pain should be able to early recognize this STEMI-equivalent ECG pattern and need to perform urgent angiography and reperfusion therapy to improve the clinical outcomes of these patients.