Introduction The de Winter Syndrome is an electrocardiogram pattern that is highly suggestive of acute occlusion of left anterior descending artery (LAD). It often presents a diagnostic challenge due to its uncommon electrocardiogram pattern which may lead to a catastrophic complication such as cardiovascular mortality. Hence, we present a case of de Winter syndrome, in which angiogram confirmed an acute occlusion of left anterior descending artery.

Case Presentation A 41-year-old gentleman, active smoker with no known medical illness previously, presented to us with sudden onset central chest pain which occurred while resting. It was described as heaviness in nature and non-radiating, associated with giddiness and nausea during the event. His ECG showed upsloping ST segment depression at the J point at V2-V6 with peaked T wave. There is also a 1 mm ST elevation in lead aVR. Subsequent ECG in ED showed no evolvement into ST elevation pattern. His troponin level was raised. We diagnosed him as de Winter Syndrome and planned for primary percutaneous intervention (PCI). Unfortunately, we were unable to proceed with PCI due to service unavailability. Subsequently, ECG in the ward showed evolvement into Wellens pattern. Angiogram on day 5 of admission confirmed 90% occlusion of the mid LAD and a stent was successfully inserted into the mid LAD. Subsequently the patient was discharge well after cardiac rehabilitation in our cardiac care unit.

Discussion De Winter pattern accounts for about 2% of patient with LAD occlusion. The ECG patterns in de Winter syndrome are upsloping ST segment depression at the J point in lead V1–V6, peaked T waves and 1–2 mm ST elevation in lead aVR. A few theories proposed as underlying aetiology such as anatomical variant, existing collateral blood supply and lack of sarcolemma ATP-sensitive potassium (KATP) channels.

Conclusion De Winter syndrome is a rare ECG pattern that is equivalent to anterior ST elevation myocardial infarction. Though fatal, it is often missed. Early recognition is crucial to ensure successful early reperfusion strategy.