Man with chest pain

A 61-year-old man with a history of hypertension and hyperlipidemia presented to the emergency department complaining of a constant left-sided chest pain present for 1 hour. On examination, his vital signs were normal other than a blood pressure of 180/100 mmHg. He was diaphoretic with an unremarkable cardiopulmonary examination. An echocardiogram (ECG) was performed (Figure 1). First described in 2008, the de Winter pattern on ECG is present in 1.6%–3.4% of anterior wall myocardial infarctions (AWMI).1-4 It is characterized by upsloping ST-segment depression at the J point in the leads V1 to V6 with associated tall, symmetrical T waves. The majority of patients also have ST-segment elevation in the augmented vector right lead and poor R-wave progression across the precordial leads, though these 2 features are not essential to make the diagnosis.5 The de Winter pattern is seen early in the course of AWMI, typically within the first 90 minutes of symptom onset.1, 3 It has a positive predictive value of over 95% for AWMI.5 It is considered by many to be a ST-segment elevation myocardial infarction equivalent and an indication for emergent reperfusion therapy.6-8 The vast majority of patients with a de Winter pattern seen on ECG will have occlusion of the proximal left anterior descending coronary artery or one of its main branches1, 2, 4 (Figure 2). Patients with the de Winter pattern as an electrocardiographic manifestation of AWMI are more likely to be male, younger, and with hyperlipidemia.3 This work has not previously been presented. No grants or other financial support was used in the preparation of this work.