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J Emerg Med. 2016 Jun;50(6):875-80. doi: 10.1016/j.jemermed.2016.03.022. Epub 2016 May 14.

Identification of the STEMI-equivalent de Winter Electrocardiogram Pattern After Ventricular Fibrillation Cardiac Arrest: A Case Report.

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Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, New Jersey.
Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, New Jersey; Emergency Medicine Residency, Newark Beth Israel Medical Center, Newark, New Jersey.



Patients with chest pain who have ST elevations on electrocardiogram (ECG) are at high risk for ST-elevation myocardial infarction (STEMI). Recent literature has reported various STEMI equivalents, which may be equally threatening. One STEMI equivalent, previously named the de Winter pattern, describes ECG changes where there are ST-segment depressions in the precordial leads in association with tall, symmetrical, hyperacute T-waves. These changes have been connected with proximal left anterior descending coronary artery occlusion.


We have identified a case of the de Winter ECG pattern immediately after ventricular fibrillation cardiac arrest. A 33-year-old man presented with waxing and waning severe substernal chest pain. The patient was on no prior medications, and had no risk factors for acute coronary syndrome. The initial ECG showed ST depression, which was followed by normalization in a repeat ECG only minutes later. The patient then developed ventricular fibrillation cardiac arrest. After defibrillation, return of spontaneous circulation was achieved and subsequent ECGs demonstrated the de Winter ECG pattern. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The characteristic ECG changes within the de Winter ECG pattern may be missed or misdiagnosed as nonspecific, reversible ischemia. This can significantly lengthen the transportation to a center equipped with a percutaneous coronary intervention laboratory, and thus the start of reperfusion therapy. It is imperative that all practitioners learn to identify this novel ECG pattern as a STEMI equivalent to ensure appropriate intervention in the cardiac catheterization laboratory.


LAD occlusion; STEMI equivalent; acute coronary syndrome; anterior wall MI; de Winter ECG; de Winter normalization

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