De Winter syndrome

A pattern of electrocardiographic changes associated with acute coronary syndrome

De Winter syndrome is a clinical condition characterized by a specific pattern of electrocardiographic (ECG) changes that are associated with an acute myocardial infarction, particularly involving the left anterior descending artery. This pattern is considered an equivalent to ST elevation myocardial infarction (STEMI) and requires urgent medical attention.

Electrocardiographic Features

ECG showing De Winter pattern

The hallmark of De Winter syndrome is the presence of upsloping ST depression at the J point in the precordial leads, along with tall, symmetrical T waves. Unlike typical STEMI, there is no ST segment elevation in the precordial leads. Instead, the ECG shows:

• Upsloping ST depression >1 mm in the precordial leads (V1-V6).
• Tall, prominent, and symmetrical T waves in the same leads.
• ST elevation in lead aVR, which may be present.

These ECG changes are indicative of a critical stenosis or occlusion of the proximal left anterior descending artery, which supplies a large portion of the left ventricle.

Pathophysiology

De Winter syndrome is thought to result from a subtotal occlusion of the left anterior descending artery. The absence of ST elevation is due to the presence of collateral circulation or partial perfusion, which prevents the full transmural ischemia typically seen in STEMI. However, the risk of complete occlusion and subsequent myocardial damage remains high.

Clinical Significance

Recognition of De Winter syndrome is crucial for timely intervention. Patients presenting with this ECG pattern should be treated as having a STEMI, with immediate consideration for percutaneous coronary intervention (PCI) or thrombolytic therapy. Delay in treatment can lead to significant myocardial damage and increased mortality.

Management

The management of De Winter syndrome involves:

• Rapid assessment and stabilization of the patient.
• Administration of antiplatelet agents such as aspirin and clopidogrel.
• Initiation of anticoagulation therapy, typically with heparin.
• Urgent coronary angiography to assess the extent of coronary artery disease.
• Revascularization, preferably through PCI, to restore blood flow.

Prognosis

The prognosis of De Winter syndrome depends on the timeliness of diagnosis and intervention. Early recognition and treatment can significantly improve outcomes by minimizing myocardial damage and preserving cardiac function.

Related pages

• Acute coronary syndrome
• Myocardial infarction
• Electrocardiography
• Coronary artery disease