Successful Thrombolysis of Dynamic De Winter’s Sign: A Case Report


De Winter's T-waves is a rarely reported Electrocardiogram (ECG) pattern requiring watchful eyes to recognize it. It was described as static sign until coronary reperfusion. This pattern was on average recorded 1.5 hours after symptom onset. It was considered as a ST-Elevated Myocardial Infarction (STEMI) equivalent pattern. We report a dynamic De Winter pattern who attended one hour of the onset of chest pain with rapid ECG changes before reperfusion.

Case Report A 62 years-old male presented within one hour after the onset of chest pain with radiation to the neck. He had no medical history. The physical exam found a regular heart rate=65 beats per minute (bpm), blood pressure=120/50 mm Hg, respiratory rate=22 cycles per minute (cpm), oxygen saturation=95% on room air. Pain intensity was evaluated seven on the 0 to 10 analog scale.

Five minutes upon arrival at the emergency department, the 18-leads initial ECG, showed normal sinus rhythm of 66 bpm, narrow QRS complexes (40 ms), a 4 mm upsloping ST depression in the apicolateral leads (V3-V6) followed by tall, symmetrical T waves and an elevation of 1 mm in aVL. ST depression and positive T waves were maximal in V3 lead. Moreover, we noted a 4 mm ST-segment depression at the J point in the inferior leads, 1 mm ST-segment depression in the posterior leads and 1mm ST-elevation in lead aVR. Clinical presentation and first ECG evoked the diagnosis of non ST-segment elevation myocardial infarction (NSTEMI). The patient was given titrated intravenous (I.V.) morphine chlorhydrate, I.V. loading dose of acetyl salicylic acid (250 mg) and oral loading dose of clopidogrel (300 mg). Highsensitivity cardiac troponin (Troponin I Hs) level was of 66.6 ng/L (normal reference for acute coronary syndrome value= 87.5 ng/L).

Eight minutes later, i.e., 73 minutes upon symptoms onset, second ECG revealed ST-segment elevation in the anteroseptal leads (V1- V4) and the high lateral leads (I- aVL). Reciprocal ST Depression was seen in the inferior leads (II, III and aVF).

As immediate Percutaneous Coronary Intervention (PCI) was not available, patient was treated with streptokinase (I.V. 1.5 million units over 45 minutes). Chest pain disappeared and ECG showed decreased ST elevation to 2 mm at 90 minutes post streptokinase infusion.