Journal of Invasive Cardiology (JIC)Occluded Left Circumflex Artery in a Patient with the de Winter Sign on Electrocardiography

🎓 Expert Commentary / Peer Perspective

A case published in the Journal of Invasive Cardiology describes de Winter ECG pattern — upsloping ST depression in V1–V4 with tall symmetrical T waves — associated with proximal LCx total occlusion and high thrombus burden, challenging the pattern’s established association with LAD occlusion exclusively.

Clinical Considerations

• The de Winter sign has been recognized as a STEMI equivalent since 2008; approximately 2% of acute MI cases from LAD occlusion exhibit this pattern
• This case represents only the second reported instance of de Winter pattern associated with LCx rather than LAD occlusion, suggesting the pattern may not be artery-specific
• Multivessel disease was present: concurrent 90–95% mid-LAD stenosis and subtotal RCA occlusion; staged PCI was completed over four days with full revascularization
• Thrombus burden required three aspiration sessions plus intracoronary tirofiban before flow was restored in the LCx territory

Practice Applications

• Recognize de Winter pattern as a STEMI equivalent mandating immediate reperfusion regardless of which coronary territory is implicated
• Consider LCx occlusion in de Winter presentations when clinical picture or echo findings do not align with expected LAD territory involvement
• Integrate thrombus aspiration and adjunctive antiplatelet therapy into the procedural approach when high thrombus burden is anticipated