Wolff-Parkinson-White syndrome and de Winter patterns; An implication for paying special attention to electrocardiogram

Ahmadi, Mostafa; Khameneh-Bagheri, Ramin; Vojdanparast, Mohammad; Jafarzadeh-Esfehani, Reza

doi:10.22122/arya.v15i4.1842

Wolff-Parkinson-White syndrome and de Winter patterns; An implication for paying special attention to electrocardiogram

Document Type : Case Report

Authors

Mostafa Ahmadi ¹

Ramin Khameneh-Bagheri ¹

Mohammad Vojdanparast ¹

Reza Jafarzadeh-Esfehani ²

¹ Assistant Professor, Department of Cardiovascular Diseases, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

² PhD Candidate, Department of Medical Genetics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

https://doi.org/10.22122/arya.v15i4.1842

Abstract

BACKGROUND: Despite recent advances in diagnostic techniques in cardiology, electrocardiography (ECG) has yet remained the first and corner stone of detecting emergency cardiac events including myocardial infarction (MI). There are some ECG findings which are considered as equivalents to MI. De Winter ST-T wave pattern is one of the important ECG findings which is thought to be related to left anterior descending artery occlusion. However, the coexistence of this ECG pattern with other ECG abnormalities are not reported widely. In this report, we discussed a unique case of de Winter ST-T wave pattern in a patient with Wolff-Parkinson-White (WPW) syndrome for the first time.CASE REPORT: A 43-year-old man was referred because of an intermittent typical chest pain. The patient had no cardiovascular risk factor, and was not on any medication; laboratory tests showed elevated and raising troponin I. The first ECG showed pre-excitation (WPW) as well as de winter pattern. According to patient’s symptoms and suggestive ECG for probable left anterior descending (LAD) occlusion, emergent angiography was scheduled. The coronary angiography revealed sever LAD artery occlusion. The patient was symptom free after successful percutaneous coronary intervention, and was discharged on medication. The patient remained asymptomatic in 1-year follow-up period.CONCLUSION: Presence of de Winter ST-T changes with other ECG abnormalities is a rare issue, and here we addressed the first case of WPW and de Winter. The physicians should be aware that ECG changes in patients with WPW should not be interpreted as de Winter ST-T changes and vice versa.

Keywords

Wolff-Parkinson-White Syndrome

Myocardial Infarction

Electrocardiography

Coronary Vessels

Rokos IC, French WJ, Mattu A, Nichol G, Farkouh ME, Reiffel J, et al. Appropriate cardiac cath lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction. Am Heart J 2010; 160(6): 995-1003, 1003.
Fiol SM, Bayes de Luna A, Carrillo LA, Garcia-Niebla J. The "de winter pattern" can progress to ST-segment elevation acute coronary syndrome. Rev Esp Cardiol (Engl Ed) 2015; 68(11): 1042-3.
Montero Cabezas JM, Karalis I, Schalij MJ. De winter electrocardiographic pattern related with a non-left anterior descending coronary artery occlusion. Ann Noninvasive Electrocardiol 2016;
(5): 526-8.
de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA. A new ECG sign of proximal LAD occlusion. N Engl J Med 2008; 359(19): 2071-3.
Carr MJ, O'Shea JT, Hinfey PB. Identification of the STEMI-equivalent de Winter electrocardiogram pattern after ventricular fibrillation cardiac arrest: A case report. J Emerg Med 2016; 50(6): 875-80.
Martinez-Losas P, Fernandez-Jimenez R. de Winter syndrome. CMAJ 2016; 188(7): 528.
Johansson BW. A history of the electrocardiogram. Dan Medicinhist Arbog 2001; 163-76.
Rao KS, Seshaiah KV, Rao DS, Pradeep TV. Incidental finding of Wolff-Parkinson-White syndrome in emergency department. J NTR Univ Health Sci 2012; 1(2): 127-9.
Skov MW, Rasmussen PV, Ghouse J, Hansen SM, Graff C, Olesen MS, et al. Electrocardiographic preexcitation and risk of cardiovascular morbidity and mortality: Results from the Copenhagen ECG study. Circ Arrhythm Electrophysiol 2017; 10(6).
Morris NP, Body R. The De Winter ECG pattern: Morphology and accuracy for diagnosing acute coronary occlusion: Systematic review. Eur J Emerg Med 2017; 24(4): 236-42.
Srivali N, Ungprasert P, Edmonds LC. Wellens syndrome presented in a patient with de winter sign electrocardiogram. Am J Emerg Med 2014; 32(5): 468-9.
Baranchuk A, Bayes-Genis A. Naming and classifying old and new ECG phenomena. CMAJ 2016; 188(7): 485-6.
Das D, Almajed NS. Wellens syndrome. CMAJ 2016; 188(7): 529.
Hennings JR, Fesmire FM. A new electrocardiographic criteria for emergent reperfusion therapy. Am J Emerg Med 2012; 30(6): 994-1000.
Finocchiaro G, Papadakis M, Behr ER, Sharma S, Sheppard M. Sudden cardiac death in pre-excitation and wolff-parkinson-white: Demographic and clinical features. J Am Coll Cardiol 2017; 69(12): 1644-5.
Liu R, Chang Q. The diagnosis of myocardial infarction in the Wolff-Parkinson-White syndrome. Int J Cardiol 2013; 167(3): 1083-4.
Obeyesekere MN, Klein GJ. Application of the 2015 ACC/AHA/HRS guidelines for risk stratification for sudden death in adult patients with asymptomatic pre-excitation. J Cardiovasc Electrophysiol 2017; 28(7): 841-8.