De winter ecg pattern: Recognizing an acute lad occlusion

The de Winter electrocardiogram (ECG) pattern is a critical STEMI equivalent indicating acute proximal Left Anterior Descending (LAD) artery occlusion, occurring in 2% of such cases and often missed by automated interpretation. We present a 41-year-old South Asian male from Kolkata with acute chest pain whose initial ECG, recorded pre-hospital, demonstrated the classic de Winter pattern, prompting pre-treatment. Emergent coronary angiography confirmed total proximal LAD occlusion (Infarct-Related Artery) and critical proximal Right Coronary Artery stenosis (Double Vessel Disease), signifying premature CAD. Successful primary Percutaneous Coronary Intervention (PCI) revascularized the LAD (TIMI III flow). Diagnosis relied on converging clinical, ECG, and imaging findings, as cardiac troponins were not measured. Post-procedure echocardiography showed moderate LV dysfunction (LVEF 40%) with corresponding wall motion abnormalities and acute diastolic dysfunction. The patient recovered uneventfully, discharged on Day 4 post-PCI with planned staged RCA PCI and comprehensive recovery support planning. This case underscores the imperative to recognize the de Winter pattern for rapid reperfusion, highlights management based on multimodal evidence when biomarkers are absent, and exemplifies the challenge of premature, complex CAD in young South Asians, a population with disproportionately high rates (incidence in young Indians ~12-16%).