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June 4, 2026BMC Cardiovascular DisordersOpen Access

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

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Why the study?

The de Winter ECG pattern raises strong suspicion for an unstable proximal LAD thrombotic culprit lesion requiring urgent evaluation despite frequently lacking conventional ST-segment elevation criteria, making recognition of STEMI equivalents critical.

Population

One 85-year-old woman with sudden-onset chest pain and prehospital atypical de Winter pattern

Design

Case report

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.

Authors

RORoland OravskýMNMartin NovákJPJonáš Pokorný

Discussion

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Overview

Atypical de Winter patterns may warrant ECG vigilance; this case leaves open prospective validation before practice change.

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

No

Structured PICO

P
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.
I
Intervention
Direct transport to PCI-capable centre, antiplatelet and anticoagulant therapy, urgent coronary angiography, and direct PCI with drug-eluting stent implantation
O
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.
  • 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

Cite This Study

Oravský et al. (2026) conducted a case report in Atypical de Winter pattern preceding anterior STEMI (n=1). Direct PCI and drug-eluting stent implantation was evaluated on Successful reperfusion and symptom resolution. 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.

synapsesocial.com/papers/6a211b86d499ed480b170fbfhttps://doi.org/10.1186/s12872-026-06051-w
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