In 2008, de Winter et al. [1] first described a new ECG sign of proximal LAD occlusion characterized mainly by up-sloping ST-segment depression at the J point in V1–6 leads, followed by tall and symmetrical T waves that accounted for approximately 2% of patients with subtotal or total occlusion of the proximal LAD artery. Then in 2018, Tsutsumi et al. [2] reported the de Winter sign in inferior leads. In our case, we illustrated an atypical style of the de Winter ECG pattern accompanied by ST elevation in inferior leads alongside specular alterations in lateral leads. To the best of our knowledge, this is the first case to present with the de Winter pattern alongside the inferior STEMI.
The mechanisms of the de Winter ECG pattern are still to be elucidated fully. Yet, it is believed that ST-segment elevation does not occur without the activation of sarcolemmal adenosine triphosphate (ATP)-sensitive potassium channels [1]. A difference in sensitivity to ischemia between endocardium and epicardium [3] and collateral blood supply might also contribute to this special ECG pattern.
Specularity is not a typical sign of de Winter pattern, since ischemia has not been transmural yet. However, we observed specular alterations of the ST segment in lateral leads, which might due to the different sensitivity to ischemia between inferior and anterior wall. ST depression in lateral leads is supposed to be the result of transmural ischemia in inferior wall.
Reportedly, the de Winter ECG pattern is transient and dynamic [4, 5]. Patients with this ECG pattern can evolve to present with ST-segment elevation in precordial leads and vice versa, possibly due to thrombus formation and autolysis [6]. In the present case, although LAD was totally occluded, we did not observe a dynamic ECG pattern, perhaps because we failed to detect pre-procedural ECG.