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236]

Case Report

de Winters pattern: Spotted and successfully

thrombolysed with streptokinase
ABSTRACT
When it comes to management of acute coronary syndrome (ACS), no other investigation can replace the role electrocardiogram (ECG) that still
holds the pivotal role in emergency rooms. Rightfully thence, the classification of ACS patients into ST elevation myocardial infarction (STEMI) or
non‑STEMI (NSTEMI) is based on these zig‑zag lines on a squared paper strip. This classification is important as both the groups differ in their
pathophysiology as well as management. While, thrombolysis or percutaneous coronary intervention is done in STEMI sufferers; thrombolysis
is contraindicated in the ones with NTEMI. There are, however, some patterns which do not show obvious ST elevation in ECG but are in fact
associated with critical narrowing of major heart vessels. de Winter is one such “NSTEMI‑STEMI equivalent.” Although now widely agreed on
as a STEMI equivalent, its management with streptokinase (STK) is controversial. We are reporting a case of 38‑year‑old male with chest pain,
whose ECG revealed the classical de Winter pattern and was successfully thrombolysed with STK. Complete set of classical ECG tracings and
its management with STK (perhaps first such report across the globe) are the two major highlights of this report.

Keywords: de Winter sign, ST elevation myocardial infarction equivalent, streptokinase, thrombolysis

INTRODUCTION
Described in 2009 and not a part of every standard scientific text
yet, de Winters pattern is not easily recognised by emergency
clinicians. Furthermore, there is controversy regarding its
management with thrombolytics. Whereas the latest European
Heart Association (EHA) and American Heart Association (AHA)
guidelines don’t recommend thrombolysis of de Winters, the
majority publications on the subject are arriving from the
western countries where the management is done with PCI.
In the West, after the advent of PCI, thrombolysis has become
obsolete from the scene as far as ACS is concerned- and the
question doesn’t hold any significance. On the contrary, in
developing economies with poor public healthcare system,
these much cheaper alternatives still hold a vital place.
CASE REPORT
A 36‑year‑old obese male, chronic smoker with negative
history of diabetes, hypertension presented in the emergency
room of Government Medical College and Guru Nanak Dev
Hospital with crushing type of intense pain in the left side of
his chest that was radiating to the left arm for around 4.5 h.
His blood pressure was 138/90 mmHg, pulse rate was recorded
to be 102/min and SpO2 was recorded to be 91% at room air.
The rest of the general physical and systemic examination was
unremarkable. Immediate electrocardiogram (ECG) [Figure 1]
was performed which revealed a very characteristic pattern
with 2–6 mm upsloping ST‑segment depression at the J point in
the precordial leads, with tall and positive symmetric T waves
with the ascending limb of the T wave commencing below
the isoelectric baseline, loss of precordial R‑wave progression,
and ST‑segment elevation of 1 mm in the lead aVR. The
changes were most striking in lead V3. These ECG changes
suggested de Winter syndrome, a condition associated
Shergill GS, Singh A, Meena NK
Department of Medicine, Government Medical College and Guru
Nanak Dev Hospital, Amritsar, Punjab, India
Address for correspondence: Dr. Gagandeep Singh Shergill,
Flat Number 3, Registrar Flats, Government Medical College and
Guru Nanak Dev Hospital, Amritsar ‑ 143 001, Punjab, India.
E‑mail: drgagandeepshergill@gmail.com

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DOI:
How to cite this article: Shergill GS, Singh A, Meena NK. de Winters
10.4103/heartindia.heartindia_30_17 pattern: Spotted and successfully thrombolysed with streptokinase. Heart
India 2017;5:157-9.

© 2017 Heart India | Published by Wolters Kluwer - Medknow 157

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Shergill, et al.: Streptokinase thrombolysis of de Winters

with acute occlusion of the left anterior descending (LAD)
coronary artery and no ST‑segment elevation. Troponin T was
measured to be as 1343 ng/ml (normal value is <0.01 ng/ml).
Due to the unavailability of Cath‑laboratory at our institute,
the financial constraints of the patient and his consent to
take the risk – we decided to thrombolyse the patient with
streptokinase (STK). Second tracing was taken immediately
after thrombolysis and it showed return of ST segment to the
baseline, and normalization of tall T waves [Figure 2]. The
third tracing was recorded 2 h after the thrombolysis and it
showed complete disappearance of STE in aVR along with
deeply inverted symmetric T waves‑indicating reperfusion
and successful thrombolysis [Figure 3]. It is worth mentioning
that the patient became pain‑free midway thrombolysis. 2D
Echo was performed the following day and it showed mild
hypokinesia of LAD territory with mildly depressed left
ventricular function. The patient was discharged after 5 days
in satisfactory condition with drug prescription, promise of
smoking‑cessation, and reduction of weight.
DISCUSSION
First recognized and reported by de Winter et al. in 2008[1]
and later replicated in findings by Verouden et al.[2] in 2009;

Figure 1: Electrocardiogram showing de Winter ST T complex in leads V2–V6, loss of precordial R-wave progression, and small ST-segment elevation in
the aVR lead

Figure 2: Electrocardiogram showing return of previous downward ST segment and tall T-waves to normal, STE in aVR has also resolved

Figure 3: There is no ST elevation in aVR, T-waves have deeply inverted – suggesting reperfusion and successful thrombolysis

158 Heart India / Volume 5 / Issue 4 / October-December 2017

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Shergill, et al.: Streptokinase thrombolysis of de Winters
the ECG pattern showing >2 mm upsloping ST‑segment
depression at the J point in the precordial leads, with tall
and positive symmetric T waves, ST‑segment elevation
of >0.5 mm in the lead aVR; is observed in about 2% patients
with proximal LAD occlusion. The de Winter pattern could
be confused with hyperacute T‑waves which occur within
minutes of coronary artery occlusion and progress rapidly to
classical ST elevation myocardial infarction (STEMI) pattern.
Latest addition to the world of ECG after Bruadas and
Wellens; this specific ECG pattern is seen in relatively young,
predominantly male and those with higher incidence of
dyslipidemia, as compared to patients with LAD occlusion
and classical STEMI on ECG.
de Winter et al. purposed that an anatomical variant of Purkinje
fibers with an endocardial conduction delay may be responsible
for the ECG changes. They also hypothesized that the absence
of ST elevation could be related to lack of activation of
sarcolemmal ATP‑sensitive potassium channels (KATP) by
ischemic ATP depletion as shown in KATP knock‑out animal
models of acute ischemia. Verouden et al. hypothesized that
patients with such pattern have a very extensive transmural
ischemic area of infarction that generates only little current
which is not sufficient to travel toward the precordial leads but
can go toward the lead aVR. The exact mechanism of evolution
of this pattern is still a matter of debate.[3,4]
Although de Winter pattern is being recognized as a STEMI
equivalent by majority,[4] since most of the cases were
associated with acute LAD occlusion and required emergent
reperfusion therapy with fibrinolysis or a primary percutaneous
coronary intervention (PCI). However, the 2013 American
College of Cardiology Foundation/American Heart Association
updated guidelines for the diagnosis and management
of STEMI do not recommend fibrinolysis/thrombolysis in
such cases.[5] Its quite expected as thrombolysis holds a
contradiction in non‑STEMI (NSTEMI) cases and the emerging
reports on the subject have used PCI for management.[6]
However, the case in hand suggests that STK can be used in
limited resources with good results.
CONCLUSION
Estimated to be present in about 2% of patients with acute
anterior wall myocardial infarction; de Winter syndrome,
a condition associated with typical chest pain and a
characteristic ECG pattern without classic ST‑segment
elevation; indicates acute total occlusion of the proximal
Heart India / Volume 5 / Issue 4 / October-December 2017
LAD. Partly due to its rarity and partly by its conspicuous
absence from the standard texts of medicine and ECG such
as Braunwald, Harrisons, API, Schamroth, and Goldberger,
it is still under‑recognized by clinicians. Not surprisingly,
we might be losing some precious lives due to ignorance.
Second, now widely believed to be a STEMI equivalent,
the treatment of this NSTEMI pattern with thrombolytic
agents is a matter of dispute with no clear guidelines. This
case is aimed to create awareness about the de Winters
pattern and to provide some inputs about the usage of
thrombolytics in its management. In a poor country like
India, where cath laboratories are absent even at tertiary
health centers, the positive outcome and guidelines could
prove immense.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. de Winter  RJ, Verouden  NJ, Wellens  HJ, Wilde AA, Interventional
Cardiology Group of the Academic Medical Center. A new ECG sign
of proximal LAD occlusion. N Engl J Med 2008;359:2071‑3.
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;95:1701‑6.
3. Goebel M, Bledsoe J, Orford JL, Mattu A, Brady WJ. A new ST‑segment
elevation myocardial infarction equivalent pattern? Prominent T wave
and J‑point depression in the precordial leads associated with ST‑segment
elevation in lead aVr. Am J Emerg Med 2014;32:287.e5‑8.
4. Baranchuk A, Bayés‑Genis A. Naming and classifying old and new ECG
phenomena. CMAJ 2016;188:485‑6.
5. American College of Emergency Physicians, Society for Cardiovascular
Angiography and Interventions, O’Gara PT, Kushner FG, Ascheim DD,
Casey DE Jr., et al. 2013 ACCF/AHA guideline for the management of
ST‑elevation myocardial infarction: A report of the American College
of Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines. J Am Coll Cardiol 2013;61:e78‑140.
6. Goyal  KK, Rajasekharan  S, Muneer  K, Sajeev  CG. De Winter sign:
A  masquerading electrocardiogram in ST‑elevation myocardial
infarction. Heart India 2017;5:48‑50.
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