Beyond the STEMI paradigm: Prevalence, predictors, and angiographic signatures of Wellens, de Winter, and Aslanger patterns in acute coronary syndromes

OBJECTIVE: Several high-risk electrocardiographic (ECG) phenotypes in acute coronary syndrome (ACS)-Wellens, de Winter, and Aslanger-signal critical ischemia or occlusion despite absent diagnostic ST-segment elevation myocardial infarction (STEMI) and would benefit from expedited reperfusion. Data on their joint estimates are scarce. The objectives were: (1) to quantify their prevalence; and (2) to compare their baseline characteristics and angiographic vessel-burden. METHODS: In this prospective single centre observational study, 1223 consecutive ACS patients undergoing invasive coronary angiography were included with their ECGs reviewed against prespecified criteria for Wellens (Types A/B), de Winter, and Aslanger pattern. Their prevalence, baseline and angiographic features were analysed. RESULTS: High-risk ECG phenotypes occurred in 71/1223 (5.8%): Wellens 48 (3.9%), Aslanger 15 (1.2%), and de Winter 8 (0.7%). Wellens presented as non-STEMI (NSTEMI) 36/48 (75%) or unstable angina (UA) 12/48 (25%), representing 10.4% (48/463) of combined NSTEMI plus UA presentations. de Winter constituted 2.3% of anterior STEMI (8/351). Aslanger accounted for 3.6% of NSTEMI (15/415). Compared to other ACS, Aslanger patients were older (69.3 ± 9.3 years) with marked metabolic clustering (diabetes 73.3%, dyslipidaemia 73.3%). Wellens (54.5 ± 11.4 years) and de Winter (54.2 ± 7.9 years) were younger and smoking-predominant (60.4% and 62.5%, respectively). Angiographically, Wellens was single-vessel disease (SVD) predominant (56.2%); de Winter localized to the left anterior descending artery (100%) and Aslanger exhibited a multivessel signature. CONCLUSIONS: About 1 in 17 (∼6%) ACS presentations exhibits a high-risk ECG phenotype not captured by STEMI criteria and each with a distinct clinico-angiographic profile. Recognizing these patterns supports an occlusion myocardial infarction (OMI) focused approach and expedited invasive management.