What is the clinical evidence from this study?

Study design: Case Report. Population: Atypical de Winter pattern preceding anterior STEMI (n=1). Intervention: Direct PCI and drug-eluting stent implantation. Primary outcome: Successful reperfusion and symptom resolution.

What question did this study set out to answer?

This case report aims to highlight the significance of recognizing atypical de Winter patterns as potential indicators of anterior STEMI.

June 4, 2026Open Access

Atypical de winter pattern preceding anterior STEMI: clinical judgement beyond rigid ECG criteria

Key Result

An atypical de Winter ECG pattern prompted early recognition of an anterior STEMI equivalent, leading to timely direct PCI of an 80% ostial LAD stenosis.

Key Points

This case report aims to highlight the significance of recognizing atypical de Winter patterns as potential indicators of anterior STEMI.
Reported a single case of an 85-year-old woman with sudden chest pain and atypical de Winter ECG pattern.
Administered antiplatelet and anticoagulant therapy prior to angiography and direct PCI treatment.
Documented evolution of ECG and anatomy response post-treatment.
Initial ECG showed atypical de Winter pattern; repeat ECG indicated typical anterior ST-segment elevation.
Coronary angiography revealed 80% ostial LAD stenosis with thrombus requiring PCI.
Emphasized the need for early recognition of STEMI equivalents to reduce reperfusion delays.

Study Design

Type

Case Report (n=1)

Multicenter

Structured PICO

Population

An 85-year-old woman presenting with sudden-onset chest pain and an atypical de Winter ECG pattern who was subsequently found to have an 80% ostial LAD stenosis with thrombus.

Intervention

Direct transport to PCI-capable centre, antiplatelet and anticoagulant therapy, urgent coronary angiography, and direct PCI with drug-eluting stent implantation

Outcome

Evolution of ECG to typical anterior ST-segment elevation and angiographic finding of 80% ostial LAD stenosis with thrombus

Early recognition of atypical de Winter ECG patterns as STEMI equivalents is crucial to minimize reperfusion delays in patients with acute coronary occlusion.

Limitations

Causality between this precise ECG phenotype and specific angiographic anatomy cannot be generalized from a single case report.
Atypical de Winter-like morphologies remain incompletely standardized.
Broader prospective validation of atypical STEMI-equivalent phenotypes remains limited.

Abstract

Background The de Winter ECG pattern should raise strong suspicion for an unstable thrombotic culprit lesion associated with high-risk anterior ischemia requiring urgent expert evaluation — classically involving the proximal left anterior descending artery (LAD) — that frequently does not fulfil conventional ST-segment elevation criteria and is therefore regarded as a STEMI equivalent. Case presentation We report the case of an 85-year-old woman with sudden-onset chest pain radiating to both shoulders. The prehospital 12-lead ECG showed atypical de Winter pattern, prompting direct transport to a PCI-capable centre and administration of antiplatelet and anticoagulant therapy. On arrival, symptoms partially improved; however, repeat ECG evolved into typical anterior ST-segment elevation. Urgent coronary angiography demonstrated an 80% ostial LAD stenosis with thrombus, successfully treated with direct PCI and drug-eluting stent implantation. Conclusion This case illustrates the dynamic nature of the de Winter-like pattern and underscores that early recognition of STEMI equivalents is crucial to minimise reperfusion delays. On the other hand, it should be emphasized that causality between this precise ECG phenotype and specific angiographic anatomy cannot be generalized from a single case report, atypical de Winter-like morphologies remain incompletely standardized, and broader prospective validation of atypical STEMI-equivalent phenotypes remains limited.

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