Case Report: De Winter electrocardiographic pattern associated with acute total left main coronary artery occlusion.

BACKGROUND: The de Winter electrocardiograph (ECG) pattern is a well-established ST-elevation myocardial infarction (STEMI) equivalent, most commonly associated with acute occlusion of the proximal left anterior descending (LAD) artery. CASE PRESENTATION: A 54-year-old man presented to the emergency department with two hours of chest pain, sweating, and nausea. The 12-lead ECG showed upsloping J-point depression in leads V2-V6 and lead I, with tall, symmetrical T waves in leads V2-V5, ST-segment elevation in lead aVR, and ST-segment depression in the inferior leads, consistent with the de Winter pattern. Emergency coronary angiography revealed total occlusion of the left main coronary artery (LMCA), and a drug-eluting stent was implanted. Due to refractory heart failure and worsening hemodynamics, the patient underwent intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO) treatment. The patient was discharged 40 days later. CONCLUSION: This case demonstrates that the de Winter ECG pattern may occasionally indicate LMCA occlusion rather than isolated LAD occlusion. In the setting of a de Winter ECG pattern accompanied by inferior lead ST-segment depression and ST-segment elevation in lead aVR, clinicians should raise clinical suspicion for LMCA occlusion-particularly in hemodynamically unstable patients-to facilitate timely and comprehensive intervention.