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

• 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
• ISSN: 2168-8184; 2168-8184
• DOI: 10.7759/cureus.24724

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.