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Acute Coronary Syndromes

Uncommon Culprit Vessel of de Winter Electrocardiogram Pattern

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1 Credit CME

JAMA Internal Medicine

Published Online: February 13, 2023

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Chia-Chen Chen, MD, MSc¹;

Bin-Yu Cai, MD²;

Xue-Wei Qi, MSc¹

Author Affiliations

¹Peking University Health Science Center, Beijing, China
²Haiyuan College of Kunming Medical University, China

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A patient in their 50s presented to the emergency department with perspiration, persistent and squeezing chest pain, and chest distress that had persisted for 90 minutes without relief. Initial physical examination revealed a body temperature of 36.3 °C, blood pressure of 90/60 mm Hg, a pulse rate of 80 beats/min, and respiratory rate of 20 breaths/min. The 12-lead electrocardiogram (ECG) is shown in the Figure. The levels of lactate dehydrogenase (LDH) and creatine kinase–MB isoenzymes (CK-MB) were 1689 (reference range, <190) U/L and 173 (reference range, <15) U/L (to convert U/L to μkat/L, multiply by 0.0167), respectively.

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A patient in their 50s presented to the emergency department with perspiration, persistent and squeezing chest pain, and chest distress that had persisted for 90 minutes without relief. Initial physical examination revealed a body temperature of 36.3 °C, blood pressure of 90/60 mm Hg, a pulse rate of 80 beats/min, and respiratory rate of 20 breaths/min. The 12-lead electrocardiogram (ECG) is shown in the Figure. The levels of lactate dehydrogenase (LDH) and creatine kinase–MB isoenzymes (CK-MB) were 1689 (reference range, <190) U/L and 173 (reference range, <15) U/L (to convert U/L to μkat/L, multiply by 0.0167), respectively.

Questions: What is the most likely diagnosis? What is the management for the diagnosis?

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Article Information

Corresponding Author: Xue-Wei Qi, MSc, Peking University Health Science Center, No. 38 Xueyuan Rd, Haidian District, Beijing 100191, China (qixuewei@pku.org.cn).

Published Online: February 13, 2023. doi:10.1001/jamainternmed.2022.6447

Conflict of Interest Disclosures: None reported.

References

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Verouden NJ , Koch KT , Peters RJ , et al. Persistent precordial “hyperacute” T-waves signify proximal left anterior descending artery occlusion. Heart. 2009;95(20):1701-1706. doi:10.1136/hrt.2009.174557 PubMed Google Scholar Crossref

Lawner BJ , Nable JV , Mattu A . Novel patterns of ischemia and STEMI equivalents. Cardiol Clin. 2012;30(4):591-599. doi:10.1016/j.ccl.2012.07.002 PubMed Google Scholar Crossref

Raja JM , Nanda A , Pour-Ghaz I , Khouzam RN . Is early invasive management as ST elevation myocardial infarction warranted in de Winter’s sign?—a “peak” into the widow-maker. Ann Transl Med. 2019;7(17):412-412. doi:10.21037/atm.2019.07.19 PubMed Google Scholar Crossref

Ando’ G , Gaspardone A , Proietti I . Acute thrombosis of the sinus node artery: arrhythmological implications. Heart. 2003;89(2):E5. doi:10.1136/heart.89.2.e5 PubMed Google Scholar Crossref

Tsutsumi K , Tsukahara K . Is the diagnosis ST-segment elevation or non–ST-segment elevation myocardial infarction? Circulation. 2018;138(23):2715-2717. doi:10.1161/CIRCULATIONAHA.118.037818 PubMed Google Scholar Crossref

Fiol M , Cygankiewicz I , Carrillo A , et al. Value of electrocardiographic algorithm based on “ups and downs” of ST in assessment of a culprit artery in evolving inferior wall acute myocardial infarction. Am J Cardiol. 2004;94(6):709-714. doi:10.1016/j.amjcard.2004.05.053 PubMed Google Scholar Crossref

Zorzi A , Perazzolo Marra M , Migliore F , Tarantini G , Iliceto S , Corrado D . Interpretation of acute myocardial infarction with persistent ‘hyperacute T waves’ by cardiac magnetic resonance. Eur Heart J Acute Cardiovasc Care. 2012;1(4):344-348. doi:10.1177/2048872612466537 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.