A 47-year-old male, smoker, with hypertension and hypercholesterolemia, presented to the emergency department with oppressive chest pain starting two hours before. The initial electrocardiogram revealed sinus rhythm at 75 bpm and Q waves and 3-6 mm ST-segment depression with high symmetrical T waves in leads V2-V3 (Figure 1), with no ST-segment elevation in leads V7-V9. A De Winter pattern was identified and the patient underwent emergent coronary angiography (Figure 2), which revealed occlusion of the proximal left anterior descending artery (LAD), followed by angioplasty and implantation of a drug-eluting stent. Electrocardiographic evolution showed QS without T waves in leads V1-V4 (Figure 3).

Figure 1.

Initial electrocardiogram showing a De Winter pattern (3-6mm ST-segment depression with high symmetrical T waves in leads V2-V3).

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Figure 2.

Angiography frame showing occlusion of the proximal left anterior descending coronary artery.

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Figure 3.

Follow-up electrocardiogram after angioplasty, showing QS without T waves in leads V1-V4.

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A De Winter pattern, characterized by ST-segment depression in precordial leads with high-amplitude positive T waves, usually reflects proximal LAD occlusion. This pattern is described in about 2% of cases of anterior myocardial infarction and is considered an ST-elevation myocardial infarction equivalent. Early recognition is essential to enable emergent reperfusion therapy and improved prognosis.