Cardiac risk factors and prevention

Heart: first published as 10.1136/heartjnl-2020-318570 on 11 February 2021. Downloaded from http://heart.bmj.com/ on July 10, 2022 at Peking University Health Science Centre CALIS.
IMAGE CHALLENGE
Typical chest pain and an
ominous ECG

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CLINICAL INTRODUCTION
A middle-­aged man in his 50s presented to our emergency depart-
ment with retrosternal chest discomfort of 2-­hour duration. His
cardiovascular risk factors included smoking and hypertension.
The patient had no history of similar episodes. On examination,
his heart rate was 72 beats per minute, and his blood pressure
was 114/74 mm Hg. The rest of the physical examination was Figure 1  Twelve-­lead ECG at presentation.
unremarkable. The ECG at presentation is shown in figure 1.
A qualitative troponin assay at the time of presentation was A. Proximal site of left anterior descending artery.
negative. B. Proximal site of a dominant right coronary artery.
C. Left main coronary artery .
QUESTION D. Proximal site of left circumflex artery.
1. Which of the following coronary artery lesions is responsible
for this specific ECG pattern ? For answer see page 432

380 Bae S, et al. Heart 2021;107:373–380. doi:10.1136/heartjnl-2020-317901

 Image challenge
Typical chest pain and an
ominous ECG
For question see page 380
Answer: A
The ECG at presentation shows ST segment depression in leads
V3–V6, II, III and aVF with ST segment elevation in leads aVR
and V1. Hyperacute T-­waves are present in the precordial leads
(figure 1). These ECG findings are suggestive of the de Winter’s
sign which is considered as a ‘STEMI equivalent’.
de Winter et al,1 in 2008, first observed an association of this
pattern with occlusion of the proximal left anterior descending
(LAD) artery .1 This sign is observed in nearly 2% of the patients
with anterior ST elevation myocardial infarction (STEMI) with
a reported positive predictive value of 95%–100% for the diag-
nosis of acute total or subtotal LAD occlusion.2 3 Rarely, this
pattern may occur in occlusion of other arteries such as left
main, diagonal and obtuse marginal.4 While the manifestations
of typical de Winter’s pattern are limited to the precordial leads,
the ST depression in the inferior leads observed in this case may
be explained by the wraparound LAD.
These patients may or may not develop ST segment elevation
in the ECG; hence, use of serial ECGs for confirming the diag-
nosis of STEMI is not rational. Furthermore, as these changes
occur early, traditional troponin assays can be falsely negative.
Figure 2  (A) Coronary angiogram in caudal right anterior oblique
projection demonstrating complete occlusion of the proximal left
anterior descending (LAD) artery (arrow). (B) Coronary angiogram after
percutaneous coronary intervention showing good flow and presence of
a wraparound LAD (arrowheads).
432   Kumar R, et al. Heart March 2021 Vol 107 No 5
Heart: first published as 10.1136/heartjnl-2020-318570 on 11 February 2021. Downloaded from http://heart.bmj.com/ on July 10, 2022 at Peking University Health Science Centre CALIS.
Failure to recognise this pattern is associated with a delay in
revascularisation and poor outcomes. While most patients with
ST depression in multiple leads or ST elevation in aVR are diag-
nosed to have non-­ST elevation acute coronary syndrome and
managed accordingly, the de Winter’s pattern warrants primary
PCI.
Coronary angiogram of our patient showed complete occlu-
sion of proximal LAD, and successful PCI with a 3.5×24 mm
drug-­eluting stent was done (figure 2).
Rahul Kumar ‍ ‍, Dinkar Bhasin ‍ ‍, Hermohander Singh Isser
Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung
Hospital, New Delhi, Delhi, India
Correspondence to Professor Hermohander Singh Isser, Cardiology, Vardhman
Mahavir Medical College and Safdarjung Hospital, New Delhi 110029, India; ​
drhsisser@​gmail.​com
Contributors  RK and DB contributed equally to this paper and are joint first
authors.All authors contributed to design, data collection, preparation and review of
the manuscript.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient and public involvement  Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.
© Author(s) (or their employer(s)) 2021. No commercial re-­use. See rights and
permissions. Published by BMJ.
Protected by copyright.
RK and DB contributed equally.
RK and DB are joint first authors.
To cite Kumar R, Bhasin D, Isser HS. Heart 2021;107:432.
Heart 2021;107:432. doi:10.1136/heartjnl-2020-318570
ORCID iDs
Rahul Kumar http://​orcid.​org/​0000-​0001-​8368-​7722
Dinkar Bhasin http://​orcid.​org/​0000-​0002-​8977-​2503
References
1 de Winter RJ, Verouden NJW, Wellens HJJ, et al. A new ECG sign of proximal LAD
occlusion. N Engl J Med 2008;359:2071–3.
2 Verouden NJ, Koch KT, Peters RJ, et al. Persistent precordial "hyperacute" T-­waves
signify proximal left anterior descending artery occlusion. Heart 2009;95:1701–6.
3 Sclarovsky S, Rechavia E, Strasberg B, et al. Unstable angina: ST segment depression
with positive versus negative T wave deflections--clinical course, ECG evolution, and
angiographic correlation. Am Heart J 1988;116:933–41.
4 Zhan Z-­Q, Li Y, Han L-­H, et al. The de winter ECG pattern: distribution and morphology
of St depression. Ann Noninvasive Electrocardiol 2020;25:e12783.