key: cord-0039364-55ej9niq
authors: Abbasian, Ahmad; Baratloo, Alireza; Abbasi, Najmeh
title: de-Winter syndrome; ST-T changes equivalent of acute myocardial infarction
date: 2019-03-13
journal: Vis J Emerg Med
DOI: 10.1016/j.visj.2019.100571
sha: 29435794c3ad09ab4589b33c19023940721d1d11
doc_id: 39364
cord_uid: 55ej9niq

nan

A 42-year-old man was admitted to the emergency room with a chief complaint of epigastric pain from three days before, which was initially waxing and waning, but short, and then became constant and severe two hours prior to admission. The pain was pushy and localized, with no radiation to the arms or back. The pain score was 8 out of 10 based on the verbal rating scale. He also reported nausea without vomiting, and had no symptoms of severe acute respiratory syndrome. His medical history suggested no similar complaints. He also had no history of heart diseases, gastrointestinal diseases, diabetes, hypertension, hyperlipidemia or hospitalization and surgery as well as no family history of coronary artery disease. The patient was a heavy smoker, but did not use alcohol or drugs. Physical examinations found the patient to be agitated but free from respiratory distress. He had a normal blood pressure of 130/80 mmHg, a normal pulse rate of 80/min and a respiratory rate of 16/min. He was found to be afebrile with an O2-saturation level of 97% on room air. His chest examination revealed the lungs were clear and the heart had muffled sounds. His other physical examinations were unremarkable. The electrocardiogram (ECG) revealed ST depression plus tall T wave in precordial leads (Fig. 1) . Given his ECG abnormalities and ongoing pain, the patient was diagnosed as a candidate for primary percutaneous coronary intervention (PPCI), and transferred to the catheterization lab. Angioplasty was performed on his left anterior descending artery (LAD) owing to coronary angiographic findings (Fig. 2) . The patient was then transferred to the CCU and discharged five days later. The ECG and angiography confirmed the diagnosis of de-Winter syndrome, which is associated with typical chest pains, characteristic ECG patterns (ST depression and tall T-waves in the precordial leads, poor R-wave progression and mild ST elevation in the AVR) and occlusion of LAD 1 . This syndrome is rare and requires PPCIs to be performed; nevertheless, physicians may fail to diagnose this condition due to the absence of classic ST elevation 2,3 .

1. Which coronary artery is occluded in de-Winter syndrome? 2. AVR lead. Explanation: Electrocardiography (ECG) showed 1-to 2mm upsloping ST-segment depression in the precordial leads, with tall and positive symmetric T waves, loss of precordial R-wave progression and small ST-segment elevation in the aVR lead.

3. Percutaneous coronary intervention. Explanation: Urgent coronary angiography shows occlusion of the left anterior descending coronary artery, which is successfully treated with angioplasty. 

A novel electrocardiographic sign of an STsegment elevation myocardial infarction-equivalent: de Winter syndrome

The de Winter ST-T pattern: an equivalent to acute coronary syndrome with ST-segment elevation

Supplementary material associated with this article can be found, in the online version, at doi:.