What is The de Winter ECG Pattern?
Ischemic heart disease (IHD), a disease that reduces the blood supply to the heart, is a leading cause of illness and death. Despite significant advances in caring for patients with acute coronary syndromes (ACS) – sudden symptoms indicating heart disease, this condition still has a considerable impact on patients’ health. In this situation, an electrocardiogram (ECG), a test that records the electrical activity of the heart, plays a crucial role in diagnosis and treatment planning. It’s important to diagnose the condition early on to implement an effective treatment plan promptly.
Distinguishing between a major heart attack (ST-segment elevation myocardial infarction, or STEMI) and a less severe heart attack (non-ST-segment elevation myocardial infarction, or NSTEMI) is vital. Over time, doctors have identified several ECG patterns linked to an increased risk of events like heart attacks or strokes.
One ECG pattern, called the de Winter pattern, strongly indicates a blockage in the left anterior descending artery, one of the main arteries supplying blood to the heart. This specific ECG pattern includes a slight depression followed by sharp, tall waves in the portion of the ECG that measures the heart’s electrical activity. This pattern is considered an indicator of a major heart attack, thus recognizing it is crucial for improving patient outcomes.
If the de Winter ECG pattern is observed, immediate consultation with a cardiologist is necessary. This consultation may result in timely heart catheterization, a procedure to examine how well your heart is working, and primary percutaneous coronary intervention, a non-surgical procedure that uses a catheter to place a stent to open up blood vessels in the heart that have been narrowed by plaque buildup. These steps are crucial to ensure proper blood flow, following the guidelines for treating major heart attacks.
What Causes The de Winter ECG Pattern?
The de Winter ECG pattern is linked to blocked coronary arteries, often the LAD. However, blockages in other coronary arteries, such as the right coronary artery and the circumflex artery, have also been reported. Most cases show blockages due to hardening of the arteries, which is similar to other causes of heart attacks. This pattern has also been seen in cases due to a blood clot.
Interestingly, the de Winter ECG pattern has also been found in situations without an immediate blockage after a procedure to improve blood flow in the coronary arteries. This is thought to be related to issues with small blood vessels not getting enough blood flow.
Risk Factors and Frequency for The de Winter ECG Pattern
The de Winter electrocardiogram pattern is a rarely seen condition that’s found in 2% to 3.4% of patients suffering from anterior myocardial infarction, a type of heart attack. This pattern is part of a condition known as Acute Coronary Syndrome (ACS). The risks connected to this pattern are the same as those for ischemic heart disease. These include:
- Being older in age
- Smoking
- Having dyslipidemia – an abnormal amount of lipids in the blood
- Hypertension – high blood pressure
- Diabetes mellitus – a chronic condition that affects how your body turns food into energy
- Obesity
Some studies show that men are more likely to exhibit this pattern, and people with this pattern generally tend to be younger than those presenting with an anterior STEMI, which is a severe form of heart attack.
Signs and Symptoms of The de Winter ECG Pattern
The de Winter ECG pattern is usually linked to a condition known as acute coronary syndrome (ACS). Patients with this pattern typically have risk factors for heart disease. These can include a family or personal history of heart disease, high blood pressure, or abnormal levels of fats in the blood. The symptoms they experience are often those associated with ACS, like severe chest pain and difficulty breathing.
Because the de Winter ECG pattern is often related to the early stages of a heart attack, a physical examination may not reveal anything unusual. However, some patients might show signs of sweating and continuous discomfort due to the acute nature of their symptoms in the context of ACS. How patients present may vary according to something known as the Killip classification system. This system was created to help with the clinical assessment of heart attack patients.
- Killip class I: patients do not show any clinical signs of heart failure.
- Killip class II: patients have crackling sounds in the lungs, higher than normal pressure in the jugular vein in their neck, and an unusual heart sound known as an S3 gallop.
- Killip class III: patients clearly have fluid build-up in their lungs.
- Killip class IV: patients are in cardiogenic shock or have low blood pressure (specifically, a systolic blood pressure less than 90 mm Hg) and signs of low cardiac output, such as producing small amounts of urine, turning blue, or having impaired mental status.
Testing for The de Winter ECG Pattern
The de Winter ECG pattern, as described in a significant study by De Winter and his team, is identified by a specific change in an electrocardiogram. This includes a gentle rise in the ST-segment, measuring between 1 to 3 mm across V1 to V6 leads. It also has tall and sharp T waves. In many cases, people also tend to show a 1 to 2 mm ST-segment elevation in lead aVR. Additionally, there could be a loss of R wave progression in the precordial leads along with QRS complexes that are of normal length or slightly broadened.
However, there are no rigid criteria to define the de Winter ECG pattern. According to a systematic review by Morris and his team, different studies classified the pattern differently. The constant feature reported in this review is the upward slope of the ST-segment mainly on lead V3, along with upright T waves. Most individuals also had poor progression of the R wave and ST-segment elevation in lead aVR. Interestingly, even though it was initially regarded as a constant pattern, there are reports suggesting a possible change in the pattern over time as the heart-related (ischemic) event progresses.
Cardiac biomarkers, specifically something called high-sensitivity cardiac troponin (hs-cTn), should be evaluated. These biomarkers help identify heart damage. However, modern guidelines emphasize that this test should not delay the heart restoration (reperfusion) strategy. Since the de Winter ECG pattern is related to an urgent type of heart issue, clinicians should understand that this biomarker may initially be within normal limits or only slightly elevated. Given the range of diagnoses this pattern can indicate, serum potassium levels can be checked to provide further information. However, this too should not delay the heart restoration strategy.
Treatment Options for The de Winter ECG Pattern
If you have risk factors or symptoms of Acute Coronary Syndrome (ACS – a group of conditions that includes heart attack and angina), and your ECG shows a specific pattern called the de Winter pattern, this could suggest that your Left Anterior Descending (LAD) artery (an important heart artery) could be blocked. This is a serious condition, and you should immediately consult with a heart doctor (cardiologist). A procedure known as cardiac catheterization may be recommended to examine how well your heart is functioning and if needed, primary Percutaneous Coronary Intervention (PCI) might be performed to restore blood flow to the heart, according to guidelines for treating severe heart attacks (STEMI).
In addition to this, medications like aspirin, a P2Y12 inhibitor (a drug to prevent blood clots), and anticoagulants (drugs that thin the blood), could be recommended by your cardiologist. After the procedure to restore blood flow is performed, you would be placed in a specialized care unit for intense monitoring like a coronary care unit or an intensive cardiac care unit. Additional tests and further treatment would proceed as per current heart-care guidelines.
What else can The de Winter ECG Pattern be?
This pattern is usually linked to the sudden blockage of the LAD artery. Yet, it can occur in other situations as well. For example, high levels of potassium in the blood, also known as hyperkalemia, can cause similar changes. However, hyperkalemia often comes with different symptoms and alters the shape of T waves in the heart rhythm.
Another scenario where such a pattern can be noticed is in the case of rapid heart rate, or tachycardia. This condition can lead to the rising depression of the ST-segment and an increase in cTn levels, which are markers of heart disease.
What to expect with The de Winter ECG Pattern
The de Winter ECG pattern is linked to a sudden blockage in a heart artery, often the LAD. Thus, it’s important to identify and address the issue promptly, which can greatly enhance the flow of blood in the blocked area and lessen the severity of the large front heart muscle injury. This can eventually improve the high rates of disease and death associated with this condition.
Preventing The de Winter ECG Pattern
Catching a condition known as ACS (Acute Coronary Syndrome) early can greatly influence how a person is treated and their overall health outcome. If a person has a blockage in their LAD (Left Anterior Descending artery – a key artery supplying oxygen-rich blood to the heart), it can lead to serious health problems. That’s why it’s crucial to remove any hurdles for people in getting medical help.
Patients should be informed about the usual signs of ACS, and the need to quickly seek medical attention if these symptoms occur. This can help ensure they get help promptly instead of waiting, which could make the condition worse by blocking blood supply for a longer time.
