De Winter syndrome may be an early electrocardiogram pattern of acute myocardial infarction, two cases report

Abstract Background De Winter syndrome is an electrocardiogram (ECG) pattern related to acute occlusion of the anterior descending artery. The incidence rate of De Winter syndrome is rare, but still requires much attention from clinicians. Methods Two patients who finnaly diagnosed with De Winter syndrome were included in our study. Results A 55‐year‐old male farmer, who was previously healthy, came to the emergency room due to sudden pain in the precordial area for 6 hours, accompanied with back pain and sweating. The second ECG revealed De Winter syndrome. Emergency coronary angiography was taken, which showed a severe atrioventricular block; diffuse stenosis in the proximal and middle segments of the left anterior descending branch, with 90% stenosis in the severest region. Percutaneous coronary intervention (PCI) of the left anterior descending artery was performed. A 70‐year‐old man with a history of hypertension arrived at the Emergency Department with chest pain for 3 hours. The first ECG was performed, which was contacted with de winter syndrome. The second ECG demonstrated acute anterior Myocardial infarction. Emergency coronary angiography showed approximately 95% stenosis at the junction of the proximal and middle segments. PCI of the proximal and middle segments of the left anterior descending artery was performed. Conclusion De Winter syndrome is a type of acute coronary syndrome, which may be an early ECG pattern in the development of acute ST‐segment elevation myocardial infarction. Therefore, once De Winter syndrome is observed on the ECG, acute coronary syndrome, especially acute anterior descending occlusion should not be ignored.

gency room due to sudden pain in the precordial area for 6 hours, accompanied with back pain and sweating. The second ECG revealed De Winter syndrome. Emergency coronary angiography was taken, which showed a severe atrioventricular block; diffuse stenosis in the proximal and middle segments of the left anterior descending branch, with 90% stenosis in the severest region. Percutaneous coronary intervention (PCI) of the left anterior descending artery was performed. A 70-year-old man with a history of hypertension arrived at the Emergency Department with chest pain for 3 hours. The first ECG was performed, which was contacted with de winter syndrome. The second ECG demonstrated acute anterior Myocardial infarction.
Emergency coronary angiography showed approximately 95% stenosis at the junction of the proximal and middle segments. PCI of the proximal and middle segments of the left anterior descending artery was performed.  2008), which is relatively rare, but still requires much attention from clinicians. Here, we report the medical history of two cases of De Winter syndrome as follows:

| CASE 1
The patient was a 55-year-old male farmer who was previously healthy. At 15:50 on April 29, 2018, the patient came to the Emergency Department (ED) of our hospital due to sudden pain in the precordial area for 6 hr. At 15:52, blood sample was collected for an emergency cardiac troponin I (cTnI) test(Beckman ASSECC2), and at 17:02, the laboratory result showed cTnI level of 0.06 ng/ml F I G U R E 1 The initial ECG of case 1 patient showed an acute extensive anterior wall myocardial infarction: Abnormal Q waves, combined with an upsloping elevation ST segment of 1.0-3.5 mm and tall, prominent, symmetric T wave appeared in the V1-V5 leads, a 0.5 mm depression of ST segment was noted in lead avR

F I G U R E 2
The second ECG of case 1 patient revealed De Winter syndrome: in the precordial leads(V2-V6) and the inferior leads (II, III, and avF) saw an upsloping ST-segment depression of 1.5-8 mm at the J point, followed by peaked, symmetric T wave. The ST-segment elevation of lead avR was about 1.5 mm, and pathological Q waves still could be seen in the leads V2-V5

| CASE 2
A 70-year-old man with a history of hypertension arrived at the ED with chest pain, which had started 3 hr before. The first ECG was performed at 16:15 on May 12, 2018, and demonstrated De Winter syndrome ( Figure 4). The cTnI level (blood sample collected at 16:07, and laboratory result obtained at 17:32) was 0.07 ng/ml (normal reference value of 0.033 ng/ml). Acute coronary syndrome (ACS) was considered, and the patient was treated with aspirin (300 mg), Plavix (300 mg), morphine (5 mg), and nitroglycerin (5 mg After PCI, the patient safely returned to the cardiac intensive care.  (Table 1). Laboratory testing for emergency cTnI requires a process of blood sample collection, separation, and analysis, which   (Xu, Wang, Liu, & Chen, 2018). When the De Winter pattern is recorded, the myocardium is still in the ischemic phase and has not progressed to complete myocardial infarction or is the result of spontaneous reperfusion after myocardial infarction (Morris & Body, 2017).

| D ISCUSS I ON
In summary, De Winter syndrome is a type of ACS, which may be an early ECG pattern in the development of AMI. Therefor, once De Winter syndrome is observed on the ECG, acute coronary syndrome, especially acute left anterior descending occlusion should not be ignored.

CO N FLI C T O F I NTE R E S T
None declared.