Discussion
The initial ECG is similar in appearance with a ST elevation myocardial infarction (STEMI) equivalent ECG pattern associated with proximal LAD occlusion which was firstly reported by de Winter et al1. The de Winter ECG pattern can be observed in a minority (2%) of symptomatic LAD artery occlusion, which is upsloping ST-segment depression at the J point followed by peaked and positive T waves, without ST-segment elevation across the precordial leads, often accompanying with a slight elevation of the ST-segment in Lead aVR and a loss of the precordial R-wave. However, contrary to previous reports, the initial ECG in our case showed upsloping ST-segment elevation in leads V1 to V3, and the specific ‘de Winter ECG pattern’ of ST-segment changes just the appearance in leads V4 to V6. Furthermore, the typical de Winter pattern J point changes to J wave. Therefore, our case showed distinct different characteristics to others.
The initial ECG in our case showed the feature of both STEMI ECG pattern and ‘de Winter ECG pattern’. It is suggested that ‘de Winter ECG pattern’ may be a transition stage towards STEMI ECG pattern. As reported by Goebel M et al.2, in a case of the de Winter ECG pattern evolving to a STEMI ECG pattern within hours. Furthermore, in our case, the specific feature of ‘de Winter pattern’ only appeared in leads V4 to V6 (lateral leads instead of anterior leads), but coronary angiography showed the same proximal-LAD occlusion as that in typical de Winter ECG pattern. Therefore, we wonder if ‘de Winter ECG pattern’ could appear in any lead and could not be exclusively associated with LAD occlusion, but has high positive predictive value for acute occlusion. Fortunately, several reports recently, further supporting this speculation3,4,5.
J wave, which associate with sudden cardiac death. It is caused by a transmural voltage gradient created by the presence of a notch in the epicardial, which has been revealed by Prof. Yan6. Although J wave has been typically associated with many pathophysiological conditions, ischemic heart disease has been rarely reported.
Practitioners should recognize this complex pattern as a high-risk ECG pattern and an urgent angiography is of great necessity.