Atypical de Winter Pattern: Clinical Judgement vs Rigid Criteria

Atypical de Winter Pattern: Clinical Judgement vs Rigid Criteria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Atypical de Winter Pattern: Clinical Judgement vs Rigid Criteria Roland Oravský, Martin Novák, Jonáš Pokorný, Jan Krejčí This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8776860/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Background The de Winter ECG pattern is a distinctive manifestation of acute coronary artery occlusion—classically involving the proximal left anterior descending artery (LAD)—that frequently does not fulfil conventional ST-segment elevation criteria and is therefore regarded as a STEMI equivalent. Case presentation: We report the case of an 85-year-old woman with sudden-onset chest pain radiating to both shoulders. The prehospital 12-lead ECG showed a de Winter–like pattern, prompting direct transport to a PCI-capable centre and administration of antiplatelet and anticoagulant therapy. On arrival, symptoms partially improved; however, repeat ECG evolved into typical anterior ST-segment elevation. Urgent coronary angiography demonstrated an 80% ostial LAD stenosis with thrombus, successfully treated with direct PCI and drug-eluting stent implantation. Conclusion This case illustrates the dynamic nature of the de Winter pattern and underscores that early recognition of STEMI equivalents is crucial to minimise reperfusion delays. de Winter pattern myocardial infarction STEMI equivalent Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction The de Winter T-wave pattern represents a specific ECG manifestation of acute coronary occlusion—most commonly in the territory of the proximal LAD—without meeting the classic criteria for ST-segment elevation. In the original description, the pattern consists of 1–3 mm upsloping ST-segment depression at the J point in leads V1–V6, continuing into tall, positive, symmetric T waves, along with concomitant ST-segment elevation in aVR (typically 1–2 mm). The ECG phenotype was first mentioned by the American cardiologist William Dressler (1890–1969) in 1947; however, formal recognition of the de Winter pattern as a distinct ECG entity occurred only in 2008, when professor Robbert Jan de Winter published the work defining this presentation, after which the eponym became widely used. ( 1 ) Subsequent observational data have shown that the pattern is relatively uncommon yet clinically highly relevant. Verouden et al. described this ECG pattern in 35 of 1,890 patients referred for primary PCI for acute LAD infarction (≈ 2%) and emphasised that it marks proximal LAD occlusion requiring immediate reperfusion. ( 2 ) A key feature of the de Winter pattern is its dynamic nature: it may persist, evolve into classic ST-segment elevation, or appear after a phase of hyperacute T waves or transient ST elevation. Therefore, in patients with ongoing symptoms, repeated ECG recordings are essential, and decision-making should be driven primarily by the clinical scenario and high-risk ECG phenotypes rather than waiting for biomarker confirmation. Case Presentation We present the case of an 85-year-old woman admitted for sudden-onset chest pain. Prior to symptom onset, she had not been under regular medical care and was not taking any chronic medication. She admitted to occasional cigarette smoking. Figure A : Prehospital 12-lead ECG – limb leads. Figure B: Prehospital 12-lead ECG – chest leads The tracing demonstrates a de Winter–like pattern with upsloping ST-segment depression in the anterior precordial leads (V2–V4) and subtle ST-segment elevation in aVR (≤ 0.5 mm). Notably, the classic de Winter morphology is incomplete: the typically tall, symmetric, “peaked” precordial T waves are absent, and in this case T-wave amplitude remains lower than the corresponding R-wave amplitude. On 31 January 2026, the patient developed sudden-onset, pressure-like chest pain radiating to both shoulders. She remained haemodynamically stable at first medical contact and throughout transport, without evidence of circulatory compromise. The prehospital 12-lead ECG was reviewed in real time in consultation with the coronary care unit physician. Although the tracing did not fulfil the formal morphological criteria of the de Winter pattern—most notably lacking the characteristic tall, symmetric, “peaked” precordial T waves—the overall configuration was nonetheless concerning for an occlusive anterior ischaemic process and a STEMI-equivalent presentation. In light of the clinical scenario and the high-risk ECG phenotype despite preserved haemodynamics, a direct transfer to our PCI-capable centre was initiated, avoiding diagnostic anchoring on haemodynamic stability or transient symptom attenuation. Prehospital antithrombotic treatment was administered, including acetylsalicylic acid 250 mg intravenously and unfractionated heparin 5,000 IU. On admission, the patient reported partial symptom relief. However, the repeat baseline ECG at the PCI centre showed dynamic evolution with development of typical ST-segment elevation in the precordial leads, consistent with an acute anterior STEMI. Urgent coronary angiography revealed an 80% ostial LAD stenosis with thrombus, treated with direct PCI, implantation of one drug-eluting stent, and administration of cangrelor. An incidental finding of 80% proximal right coronary artery (RCA) stenosis was noted and scheduled for elective PCI. Figure C. Admission ECG at the PCI centre. Repeat 12-lead ECG on arrival demonstrates dynamic evolution of the initial ischaemic pattern with progression to typical anterior ST-segment elevation, consistent with an acute anterior STEMI. Because a STEMI-equivalent was suspected on the prehospital ECG, coronary angiography was performed within recommended time limits, within 120 minutes of symptom onset. After acute invasive management, the patient remained clinically stable and became symptom-free. Guideline-directed pharmacotherapy for acute coronary syndrome was initiated. The in-hospital course was uncomplicated, and the patient was discharged to outpatient cardiology follow-up. Figure D. Coronary angiography (culprit lesion). Coronary angiography demonstrates an 80% ostial stenosis of the left anterior descending artery (LAD) with visible thrombus. The lesion was treated with direct PCI, implantation of a single drug-eluting stent (DES), and adjunctive cangrelor administration. Figure E. Final angiographic result. Post-intervention angiography shows an optimal PCI result in the LAD with restoration of TIMI grade 3 flow. Discussion The formal definition of the de Winter pattern has remained unchanged since 2008. However, it is increasingly recognised that the de Winter presentation is not a single rigidly defined morphology but rather a phenotype within a broader spectrum of ECG manifestations of occlusive myocardial infarction (OMI)—a dynamic entity that may evolve over time (e.g., conversion to typical ST-segment elevation or, conversely, emergence after hyperacute T waves). Clinically, it is crucial that the literature repeatedly describes atypical or “de Winter–like” presentations that do not match the original 2008 morphological description yet may still be associated with angiographically confirmed acute thrombotic occlusion or a critical culprit coronary lesion, carrying the same implication of an urgent invasive strategy. These include, in particular: Variations in ST-segment depression : ST depression is not invariably “upsloping” and may differ in morphology or in the distribution of maximal depression. Some reports suggest that the localisation/morphology of ST depression may vary depending on the aetiology (LAD occlusion vs other causes of a de Winter–like pattern). ( 3 ) “Mirror-image” variants : Cases have been reported in which the ECG resembles a de Winter pattern but, on careful assessment, does not fulfil criteria, or is interpreted as a “mirror” variant of a different ischaemic pattern. ( 4 ) Culprit lesions other than the proximal LAD : Although classically linked to LAD occlusion, de Winter–like patterns have been reported with lesions in other vessels (e.g., a diagonal branch), increasing the risk of under-recognition if the pattern is interpreted too narrowly. ( 5 ) Atypical de Winter with proven proximal LAD occlusion : Case reports describe angiographically confirmed acute thrombotic proximal LAD occlusion with an ECG presentation that is “atypical” relative to the original description—highlighting that rigid checklist-based interpretation can delay reperfusion. ( 6 ) The de Winter pattern is now regarded as a STEMI equivalent, i.e., an acute coronary occlusion requiring the same urgent invasive approach as STEMI. A major pitfall is misclassifying the de Winter pattern as “non-specific” ST depression or as subendocardial ischaemia, which may alter the therapeutic strategy inappropriately. Notably, the upsloping ST depression characteristic of de Winter morphology may even be interpreted as a normal finding during exercise — further underlining the importance of clinical context. Contemporary reviews of acute coronary syndromes with ongoing myocardial ischaemia—framed by some authors under the OMI concept—classify the de Winter pattern among high-risk ECG presentations that should trigger cath lab activation and urgent coronary angiography. These sources also note that the de Winter pattern can be viewed as a more readily recognisable subtype within the broader category of hyperacute T-wave presentations. ( 7 ) Table 1 List of other STEMI-equivalents Several scenarios in which coronary occlusion or global ischaemia may be present without typical ST-segment elevation and in which a primary PCI strategy should be considered Isolated posterior myocardial infarction often due to left circumflex involvement: typically ST depression in V1–V3; posterior leads V7–V9 are recommended (diagnostic threshold ≥ 0.5 mm ST elevation; in men < 40 years ≥ 1 mm) Suspected left main coronary artery lesion or severe multivessel ischaemia diffuse ST depression (≥ 1 mm in ≥ 8 leads) with ST elevation in aVR and/or V1—especially with haemodynamic instability Bundle branch block or paced rhythm “standard STEMI criteria” may fail (LBBB, ventricular pacing): use dedicated criteria interpreted in clinical context Hyperacute T waves as an early manifestation of occlusion Aslanger pattern ST elevation isolated in lead III with diffuse ST depression; often multivessel disease plus acute inferior-territory occlusion South African flag sign subtle ST elevation in I, aVL, and V2 with ST depression in III; typically associated with diagonal branch occlusion Conclusion The de Winter T-wave pattern is a high-risk ECG phenotype consistent with occlusive myocardial infarction, most commonly due to proximal LAD involvement, and in an appropriate clinical context should be treated as a STEMI equivalent, warranting urgent coronary angiography and reperfusion. Failure to recognise this pattern, particularly when it presents in an atypical or “de Winter–like” form, may result in delayed reperfusion and larger infarct size. In many healthcare settings, a haemodynamically stable patient with non-STEMI ECG findings may initially be transported to, or evaluated at, a hospital without on-site PCI capability, necessitating secondary inter-hospital transfer if an occlusive infarction is subsequently recognised. Early identification of a STEMI equivalent beyond rigid morphological criteria (as de Winter-like ECG pattern as in this case study) in the prehospital phase can therefore be decisive, enabling direct triage to a PCI-capable centre and reducing system-related delays; in the present case, this strategy facilitated reperfusion therapy within the recommended 120-minute time window from symptom onset Abbreviations DES drug-eluting stent LAD left anterior descending coronary artery OMI occlusive myocardial infarction PCI percutaneous coronary intervention RCA right coronary artery Declarations Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent for publication of identifying images and other personal or clinical details was obtained from the patient. Availability of data and materials Not applicable. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors´ contribution RO gathered all patient data and prepared the original version of the manuscript. He is a physician who, while on duty, recognized a STEMI-equivalent pattern on the ECG and initiated urgent transfer to a PCI centre. MN and JP are interventional cardiologists who performed the urgent coronary angiography and direct PCI. JK is the group leader who provided supervision regarding manuscript preparation and data interpretation. All authors read and approved the final manuscript. Acknowledgements Not applicable. References de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA, Interventional Cardiology Group of the Academic Medical Center. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008;359(19):2071-3. 10.1056/NEJMc0804737 . PMID: 18987380. Verouden NJ, Koch KT, Peters RJ, Henriques JP, Baan J, van der Schaaf RJ, Vis MM, Tijssen JG, Piek JJ, Wellens HJ, Wilde AA, de Winter RJ. Persistent precordial hyperacute T-waves signify proximal left anterior descending artery occlusion. Heart. 2009;95(20):1701–6. 10.1136/hrt.2009.174557 . Epub 2009 Jul 19. PMID: 19620137. Zhan ZQ, Li Y, Han LH, Nikus KC, Birnbaum Y, Baranchuk A. The de Winter ECG pattern: Distribution and morphology of ST depression. Ann Noninvasive Electrocardiol. 2020;25(5):e12783. 10.1111/anec.12783 . Epub 2020 Jun 25. PMID: 32588536; PMCID: PMC7507532. Wang J, Li J, Diao S, Xu H, Ding F. Atypical de Winter ECG pattern may be the mirror image of ST elevation. Ann Noninvasive Electrocardiol. 2022;27(3):e12915. 10.1111/anec.12915 . Epub 2021 Nov 22. PMID: 34808022; PMCID: PMC9107089. Ni H, Zhai C, Pan H. Uncommon culprit artery leading to atypical de winter electrocardiographic changes: a case report. BMC Cardiovasc Disord. 2024;24:524. https://doi.org/10.1186/s12872-024-04208-z . Yang W, Liu H, Zhu M, Song Z. The de Winter electrocardiographic pattern of proximal left anterior descending occlusion. Am J Emerg Med. 2017;35(6):937. 10.1016/j.ajem.2016.12.041 . .e1-937.e3 . Epub 2016 Dec 16. PMID: 27998614. Ricci F, Martini C, Scordo DM, Rossi D, Gallina S, Fedorowski A, Sciarra L, Chahal CAA, Meyers HP, Herman R, Smith SW. ECG Patterns of Occlusion Myocardial Infarction: A Narrative Review. Ann Emerg Med. 2025;85(4):330–40. Epub 2025 Jan 17. PMID: 39818676. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 17 Mar, 2026 Reviews received at journal 14 Mar, 2026 Reviews received at journal 04 Mar, 2026 Reviewers agreed at journal 04 Mar, 2026 Reviewers agreed at journal 03 Mar, 2026 Reviewers agreed at journal 02 Mar, 2026 Reviews received at journal 22 Feb, 2026 Reviewers agreed at journal 22 Feb, 2026 Reviewers agreed at journal 19 Feb, 2026 Reviewers invited by journal 19 Feb, 2026 Editor invited by journal 06 Feb, 2026 Editor assigned by journal 05 Feb, 2026 Submission checks completed at journal 05 Feb, 2026 First submitted to journal 03 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8776860","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":595142371,"identity":"700f27e8-0978-4216-beb3-41afa8f59e9b","order_by":0,"name":"Roland Oravský","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYFAC5gYGBjYIk7GBwYafCC2MKFrSJBtI1XKYsBbz9sbGzwVlDHLm7WeMP85sOy9hLpH+8ANDTR1OLTJnDjZLzzjHYCxzJsdMcmPbbQnLGTnGEgzH2HBqkZBIbJDmbWNInMGQlsb4sO12ncGNHAYJxgYefFqaf4O18D9L/viw7ZyEwY30xz8YGyTwaWmD2CKRfADosANALQlmQFsMcGvhOdhmzXNOwlhC4vExyRnnkiUMzrwxs0g4loBbC3vz4ds8ZTZyEvyJzR97yuwkDI6nP77xAU+IwXRCKEZYOOG2AwP8IV7pKBgFo2AUjBwAAAxFUBBFptjzAAAAAElFTkSuQmCC","orcid":"","institution":"St. Anne’s University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Roland","middleName":"","lastName":"Oravský","suffix":""},{"id":595142372,"identity":"65c08045-db32-4f36-84cf-784dfc9c7033","order_by":1,"name":"Martin Novák","email":"","orcid":"","institution":"St. Anne’s University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Novák","suffix":""},{"id":595142373,"identity":"fa4c3edd-abfd-4c05-b347-1805a0dd0a49","order_by":2,"name":"Jonáš Pokorný","email":"","orcid":"","institution":"St. Anne’s University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jonáš","middleName":"","lastName":"Pokorný","suffix":""},{"id":595142374,"identity":"5fb8443d-3c8a-4c6e-a0ea-7036b7514cf9","order_by":3,"name":"Jan Krejčí","email":"","orcid":"","institution":"St. Anne’s University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jan","middleName":"","lastName":"Krejčí","suffix":""}],"badges":[],"createdAt":"2026-02-03 14:08:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8776860/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8776860/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103345716,"identity":"e3f973f8-ed65-4e15-b3f1-a59d7197e73c","added_by":"auto","created_at":"2026-02-24 16:13:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":534719,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFigure A:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003e\u003cem\u003e\u003cstrong\u003ePrehospital 12-lead ECG – limb leads.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8776860/v1/3b380bd07fef00c13de8b15d.png"},{"id":103345717,"identity":"38b5dc67-a41f-4843-b331-68077c5d5101","added_by":"auto","created_at":"2026-02-24 16:13:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":416784,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFigure B: Prehospital 12-lead ECG – chest leads\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8776860/v1/33e8f124309022812f8607e7.png"},{"id":103345714,"identity":"0279df31-7eb5-4ba6-b9f0-4e66b0f79cf8","added_by":"auto","created_at":"2026-02-24 16:13:51","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":453868,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFigure C. Admission ECG at the PCI centre.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8776860/v1/5ded871448f71895a855717b.png"},{"id":103507295,"identity":"113203ef-0c45-4e03-bee4-67ec9fc3e30b","added_by":"auto","created_at":"2026-02-26 13:40:55","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":176871,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFigure D. Coronary angiography (culprit lesion).\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8776860/v1/cfd1fc57d1fe3be5f86fc9bf.png"},{"id":103345713,"identity":"9e105dc0-2a3d-440d-b9cd-5cd4913bb1f4","added_by":"auto","created_at":"2026-02-24 16:13:51","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":161658,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eFigure E. Final angiographic result.\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8776860/v1/bdf415f56d3ff880f8fb5038.png"},{"id":103511864,"identity":"ea4d6c22-a897-44a3-8508-3798a07e4c8d","added_by":"auto","created_at":"2026-02-26 14:11:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2481914,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8776860/v1/9673cccc-8cd0-42b2-abf1-292dc4e8a816.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Atypical de Winter Pattern: Clinical Judgement vs Rigid Criteria","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe de Winter T-wave pattern represents a specific ECG manifestation of acute coronary occlusion\u0026mdash;most commonly in the territory of the proximal LAD\u0026mdash;without meeting the classic criteria for ST-segment elevation. In the original description, the pattern consists of 1\u0026ndash;3 mm upsloping ST-segment depression at the J point in leads V1\u0026ndash;V6, continuing into tall, positive, symmetric T waves, along with concomitant ST-segment elevation in aVR (typically 1\u0026ndash;2 mm).\u003c/p\u003e \u003cp\u003eThe ECG phenotype was first mentioned by the American cardiologist William Dressler (1890\u0026ndash;1969) in 1947; however, formal recognition of the de Winter pattern as a distinct ECG entity occurred only in 2008, when professor Robbert Jan de Winter published the work defining this presentation, after which the eponym became widely used. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSubsequent observational data have shown that the pattern is relatively uncommon yet clinically highly relevant. Verouden et al. described this ECG pattern in 35 of 1,890 patients referred for primary PCI for acute LAD infarction (\u0026asymp;\u0026thinsp;2%) and emphasised that it marks proximal LAD occlusion requiring immediate reperfusion. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) A key feature of the de Winter pattern is its dynamic nature: it may persist, evolve into classic ST-segment elevation, or appear after a phase of hyperacute T waves or transient ST elevation. Therefore, in patients with ongoing symptoms, repeated ECG recordings are essential, and decision-making should be driven primarily by the clinical scenario and high-risk ECG phenotypes rather than waiting for biomarker confirmation.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eWe present the case of an 85-year-old woman admitted for sudden-onset chest pain. Prior to symptom onset, she had not been under regular medical care and was not taking any chronic medication. She admitted to occasional cigarette smoking.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure A\u003c/b\u003e: \u003cb\u003ePrehospital 12-lead ECG \u0026ndash; limb leads. Figure B: Prehospital 12-lead ECG \u0026ndash; chest leads\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe tracing demonstrates a de Winter\u0026ndash;like pattern with upsloping ST-segment depression in the anterior precordial leads (V2\u0026ndash;V4) and subtle ST-segment elevation in aVR (\u0026le;\u0026thinsp;0.5 mm). Notably, the classic de Winter morphology is incomplete: the typically tall, symmetric, \u0026ldquo;peaked\u0026rdquo; precordial T waves are absent, and in this case T-wave amplitude remains lower than the corresponding R-wave amplitude.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOn 31 January 2026, the patient developed sudden-onset, pressure-like chest pain radiating to both shoulders. She remained haemodynamically stable at first medical contact and throughout transport, without evidence of circulatory compromise. The prehospital 12-lead ECG was reviewed in real time in consultation with the coronary care unit physician. Although the tracing did not fulfil the formal morphological criteria of the de Winter pattern\u0026mdash;most notably lacking the characteristic tall, symmetric, \u0026ldquo;peaked\u0026rdquo; precordial T waves\u0026mdash;the overall configuration was nonetheless concerning for an occlusive anterior ischaemic process and a STEMI-equivalent presentation. In light of the clinical scenario and the high-risk ECG phenotype despite preserved haemodynamics, a direct transfer to our PCI-capable centre was initiated, avoiding diagnostic anchoring on haemodynamic stability or transient symptom attenuation. Prehospital antithrombotic treatment was administered, including acetylsalicylic acid 250 mg intravenously and unfractionated heparin 5,000 IU.\u003c/p\u003e \u003cp\u003e On admission, the patient reported partial symptom relief. However, the repeat baseline ECG at the PCI centre showed dynamic evolution with development of typical ST-segment elevation in the precordial leads, consistent with an acute anterior STEMI. Urgent coronary angiography revealed an 80% ostial LAD stenosis with thrombus, treated with direct PCI, implantation of one drug-eluting stent, and administration of cangrelor. An incidental finding of 80% proximal right coronary artery (RCA) stenosis was noted and scheduled for elective PCI.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure C. Admission ECG at the PCI centre.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eRepeat 12-lead ECG on arrival demonstrates dynamic evolution of the initial ischaemic pattern with progression to typical anterior ST-segment elevation, consistent with an acute anterior STEMI.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Because a STEMI-equivalent was suspected on the prehospital ECG, coronary angiography was performed within recommended time limits, within 120 minutes of symptom onset. After acute invasive management, the patient remained clinically stable and became symptom-free. Guideline-directed pharmacotherapy for acute coronary syndrome was initiated. The in-hospital course was uncomplicated, and the patient was discharged to outpatient cardiology follow-up.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure D. Coronary angiography (culprit lesion).\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eCoronary angiography demonstrates an 80% ostial stenosis of the left anterior descending artery (LAD) with visible thrombus. The lesion was treated with direct PCI, implantation of a single drug-eluting stent (DES), and adjunctive cangrelor administration.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure E. Final angiographic result.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003ePost-intervention angiography shows an optimal PCI result in the LAD with restoration of TIMI grade 3 flow.\u003c/em\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe formal definition of the de Winter pattern has remained unchanged since 2008. However, it is increasingly recognised that the de Winter presentation is not a single rigidly defined morphology but rather a phenotype within a broader spectrum of ECG manifestations of occlusive myocardial infarction (OMI)\u0026mdash;a dynamic entity that may evolve over time (e.g., conversion to typical ST-segment elevation or, conversely, emergence after hyperacute T waves).\u003c/p\u003e \u003cp\u003eClinically, it is crucial that the literature repeatedly describes atypical or \u0026ldquo;de Winter\u0026ndash;like\u0026rdquo; presentations that do not match the original 2008 morphological description yet may still be associated with angiographically confirmed acute thrombotic occlusion or a critical culprit coronary lesion, carrying the same implication of an urgent invasive strategy. These include, in particular:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eVariations in ST-segment depression\u003c/b\u003e: ST depression is not invariably \u0026ldquo;upsloping\u0026rdquo; and may differ in morphology or in the distribution of maximal depression. Some reports suggest that the localisation/morphology of ST depression may vary depending on the aetiology (LAD occlusion vs other causes of a de Winter\u0026ndash;like pattern). (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;Mirror-image\u0026rdquo; variants\u003c/b\u003e: Cases have been reported in which the ECG resembles a de Winter pattern but, on careful assessment, does not fulfil criteria, or is interpreted as a \u0026ldquo;mirror\u0026rdquo; variant of a different ischaemic pattern. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eCulprit lesions other than the proximal LAD\u003c/b\u003e: Although classically linked to LAD occlusion, de Winter\u0026ndash;like patterns have been reported with lesions in other vessels (e.g., a diagonal branch), increasing the risk of under-recognition if the pattern is interpreted too narrowly. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eAtypical de Winter with proven proximal LAD occlusion\u003c/b\u003e: Case reports describe angiographically confirmed acute thrombotic proximal LAD occlusion with an ECG presentation that is \u0026ldquo;atypical\u0026rdquo; relative to the original description\u0026mdash;highlighting that rigid checklist-based interpretation can delay reperfusion. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe de Winter pattern is now regarded as a STEMI equivalent, i.e., an acute coronary occlusion requiring the same urgent invasive approach as STEMI. A major pitfall is misclassifying the de Winter pattern as \u0026ldquo;non-specific\u0026rdquo; ST depression or as subendocardial ischaemia, which may alter the therapeutic strategy inappropriately. Notably, the upsloping ST depression characteristic of de Winter morphology may even be interpreted as a normal finding during exercise \u0026mdash; further underlining the importance of clinical context.\u003c/p\u003e \u003cp\u003eContemporary reviews of acute coronary syndromes with ongoing myocardial ischaemia\u0026mdash;framed by some authors under the OMI concept\u0026mdash;classify the de Winter pattern among high-risk ECG presentations that should trigger cath lab activation and urgent coronary angiography. These sources also note that the de Winter pattern can be viewed as a more readily recognisable subtype within the broader category of hyperacute T-wave presentations. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eList of other STEMI-equivalents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSeveral scenarios in which coronary occlusion or global ischaemia may be present without typical ST-segment elevation and in which a primary PCI strategy should be considered\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIsolated posterior myocardial infarction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eoften due to left circumflex involvement: typically ST depression in V1\u0026ndash;V3; posterior leads V7\u0026ndash;V9 are recommended (diagnostic threshold\u0026thinsp;\u0026ge;\u0026thinsp;0.5 mm ST elevation; in men\u0026thinsp;\u0026lt;\u0026thinsp;40 years\u0026thinsp;\u0026ge;\u0026thinsp;1 mm)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSuspected left main coronary artery lesion or severe multivessel ischaemia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ediffuse ST depression (\u0026ge;\u0026thinsp;1 mm in \u0026ge;\u0026thinsp;8 leads) with ST elevation in aVR and/or V1\u0026mdash;especially with haemodynamic instability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBundle branch block or paced rhythm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ldquo;standard STEMI criteria\u0026rdquo; may fail (LBBB, ventricular pacing): use dedicated criteria interpreted in clinical context\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHyperacute T waves\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eas an early manifestation of occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAslanger pattern\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eST elevation isolated in lead III with diffuse ST depression; often multivessel disease plus acute inferior-territory occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSouth African flag sign\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esubtle ST elevation in I, aVL, and V2 with ST depression in III; typically associated with diagonal branch occlusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe de Winter T-wave pattern is a high-risk ECG phenotype consistent with occlusive myocardial infarction, most commonly due to proximal LAD involvement, and in an appropriate clinical context should be treated as a STEMI equivalent, warranting urgent coronary angiography and reperfusion. Failure to recognise this pattern, particularly when it presents in an atypical or \u0026ldquo;de Winter\u0026ndash;like\u0026rdquo; form, may result in delayed reperfusion and larger infarct size. In many healthcare settings, a haemodynamically stable patient with non-STEMI ECG findings may initially be transported to, or evaluated at, a hospital without on-site PCI capability, necessitating secondary inter-hospital transfer if an occlusive infarction is subsequently recognised. Early identification of a STEMI equivalent beyond rigid morphological criteria (as de Winter-like ECG pattern as in this case study) in the prehospital phase can therefore be decisive, enabling direct triage to a PCI-capable centre and reducing system-related delays; in the present case, this strategy facilitated reperfusion therapy within the recommended 120-minute time window from symptom onset\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDES\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;drug-eluting stent\u003c/p\u003e\n\u003cp\u003eLAD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;left anterior descending coronary artery\u003c/p\u003e\n\u003cp\u003eOMI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;occlusive myocardial infarction\u003c/p\u003e\n\u003cp\u003ePCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;percutaneous coronary intervention\u003c/p\u003e\n\u003cp\u003eRCA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; right coronary artery\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of identifying images and other personal or clinical details was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026acute; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRO gathered all patient data and prepared the original version of the manuscript. He is a physician who, while on duty, recognized a STEMI-equivalent pattern on the ECG and initiated urgent transfer to a PCI centre. MN and JP are interventional cardiologists who performed the urgent coronary angiography and direct PCI. JK is the group leader who provided supervision regarding manuscript preparation and data interpretation. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ede Winter RJ, Verouden NJ, Wellens HJ, Wilde AA, Interventional Cardiology Group of the Academic Medical Center. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008;359(19):2071-3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMc0804737\u003c/span\u003e\u003cspan address=\"10.1056/NEJMc0804737\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 18987380.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVerouden NJ, Koch KT, Peters RJ, Henriques JP, Baan J, van der Schaaf RJ, Vis MM, Tijssen JG, Piek JJ, Wellens HJ, Wilde AA, de Winter RJ. Persistent precordial hyperacute T-waves signify proximal left anterior descending artery occlusion. Heart. 2009;95(20):1701\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/hrt.2009.174557\u003c/span\u003e\u003cspan address=\"10.1136/hrt.2009.174557\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2009 Jul 19. PMID: 19620137.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhan ZQ, Li Y, Han LH, Nikus KC, Birnbaum Y, Baranchuk A. The de Winter ECG pattern: Distribution and morphology of ST depression. Ann Noninvasive Electrocardiol. 2020;25(5):e12783. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/anec.12783\u003c/span\u003e\u003cspan address=\"10.1111/anec.12783\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2020 Jun 25. PMID: 32588536; PMCID: PMC7507532.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang J, Li J, Diao S, Xu H, Ding F. Atypical de Winter ECG pattern may be the mirror image of ST elevation. Ann Noninvasive Electrocardiol. 2022;27(3):e12915. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/anec.12915\u003c/span\u003e\u003cspan address=\"10.1111/anec.12915\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2021 Nov 22. PMID: 34808022; PMCID: PMC9107089.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNi H, Zhai C, Pan H. Uncommon culprit artery leading to atypical de winter electrocardiographic changes: a case report. BMC Cardiovasc Disord. 2024;24:524. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12872-024-04208-z\u003c/span\u003e\u003cspan address=\"10.1186/s12872-024-04208-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang W, Liu H, Zhu M, Song Z. The de Winter electrocardiographic pattern of proximal left anterior descending occlusion. Am J Emerg Med. 2017;35(6):937. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajem.2016.12.041\u003c/span\u003e\u003cspan address=\"10.1016/j.ajem.2016.12.041\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.e1-937.e3\u003c/span\u003e\u003cspan address=\"http://.e1-937.e3\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2016 Dec 16. PMID: 27998614.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRicci F, Martini C, Scordo DM, Rossi D, Gallina S, Fedorowski A, Sciarra L, Chahal CAA, Meyers HP, Herman R, Smith SW. ECG Patterns of Occlusion Myocardial Infarction: A Narrative Review. Ann Emerg Med. 2025;85(4):330\u0026ndash;40. Epub 2025 Jan 17. PMID: 39818676.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"de Winter pattern, myocardial infarction, STEMI equivalent","lastPublishedDoi":"10.21203/rs.3.rs-8776860/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8776860/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe de Winter ECG pattern is a distinctive manifestation of acute coronary artery occlusion\u0026mdash;classically involving the proximal left anterior descending artery (LAD)\u0026mdash;that frequently does not fulfil conventional ST-segment elevation criteria and is therefore regarded as a STEMI equivalent.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eWe report the case of an 85-year-old woman with sudden-onset chest pain radiating to both shoulders. The prehospital 12-lead ECG showed a de Winter\u0026ndash;like pattern, prompting direct transport to a PCI-capable centre and administration of antiplatelet and anticoagulant therapy. On arrival, symptoms partially improved; however, repeat ECG evolved into typical anterior ST-segment elevation. Urgent coronary angiography demonstrated an 80% ostial LAD stenosis with thrombus, successfully treated with direct PCI and drug-eluting stent implantation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case illustrates the dynamic nature of the de Winter pattern and underscores that early recognition of STEMI equivalents is crucial to minimise reperfusion delays.\u003c/p\u003e","manuscriptTitle":"Atypical de Winter Pattern: Clinical Judgement vs Rigid Criteria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 16:13:46","doi":"10.21203/rs.3.rs-8776860/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-17T12:28:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T10:23:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T04:23:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166852309863534724164387557980026362986","date":"2026-03-05T04:15:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53045398393198703038848209375702177323","date":"2026-03-04T03:42:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244772698281364598601388225191489145076","date":"2026-03-02T14:40:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-22T13:52:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35137662058770120775904574737871960685","date":"2026-02-22T13:08:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146329207681564694823392181090432313775","date":"2026-02-19T07:42:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-19T05:02:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-06T13:21:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-05T10:01:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-05T09:54:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2026-02-03T13:32:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4368a3c9-e4e2-47cf-8aff-8507ecc98658","owner":[],"postedDate":"February 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T08:54:50+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-24 16:13:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8776860","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8776860","identity":"rs-8776860","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}