Atypical de Winter Presentation of Critical Left Anterior Descending Coronary Artery Occlusion

A 69-year-old male presented with substernal chest pain that started a few hours earlier. On arrival, the patient was hemodynamically stable, and the physical examination was unrevealing. Laboratory workup revealed an elevated high-sensitivity troponin, and an initial electrocardiogram (ECG) reveale...

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Bibliographic Details
Published in:Curēus (Palo Alto, CA) CA), 2022-05, Vol.14 (5), p.e24724
Main Authors: Kainat, Aleesha, Ain, Noor Ul, Boricha, Hetal, Gulzar, Mahdin, Dueweke, Eric J
Format: Article
Language:English
Subjects:
Acute coronary syndromes
Angioplasty
Anticoagulants
Cardiac arrhythmia
Cardiac catheterization
Cardiology
Cardiovascular disease
Case reports
Coronary vessels
Electrocardiography
Emergency medical care
Emergency Medicine
Heart attacks
Heart rate
Internal Medicine
Intubation
Laboratories
Pain
Patients
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Summary:A 69-year-old male presented with substernal chest pain that started a few hours earlier. On arrival, the patient was hemodynamically stable, and the physical examination was unrevealing. Laboratory workup revealed an elevated high-sensitivity troponin, and an initial electrocardiogram (ECG) revealed tall, symmetric T-waves with preceding minor concave ST-segment elevations less than 1 mm in the precordial leads (V1-V6) and 0.5 mm ST elevation in the aVR. Due to concerning ECG changes, the patient was treated for a possible non-ST-segment elevation myocardial infarction. A loading dose of aspirin and clopidogrel was given and a heparin drip was initiated. However, the patient's chest pain persisted requiring multiple sublingual nitroglycerin tablets. Later, on further review of the ECGs, the presence of de Winter T-waves was noted and led to activation of the catheterization laboratory, and an urgent left heart catheterization (LHC) was done. LHC revealed a critical 90% occlusion of the left anterior descending artery, and a drug-eluting stent was placed. The patient had a good recovery thereafter. This case emphasizes the rarity of the case and lack of awareness about the atypical de Winter pattern that is considered to be an ST-segment elevation myocardial infarction equivalent. Failure to recognize this can potentially lead to delayed intervention.
ISSN:2168-8184
2168-8184
DOI:10.7759/cureus.24724