STEMI equivalent but STEMI!

Aravinda Kumar1,*, R. Haridha Devi2

1Chief Consultant Interventional Cardiologist, Kauvery Hospital, Heartcity, Trichy

2Duty Medical Officer, Kauvery Hospital, Heartcity, Trichy



In the field of medicine, the ability to recognize and interpret electrocardiograms (ECGs) is of utmost importance, especially when it comes to diagnosing cardiac conditions. Among the various ECG patterns that exist, one rare but significant finding is De Winters sign. This pattern, first described by Drs. Hein J.J. De Winter and Gerard S.R.M. Holtkamp in 2008, is characterized by ST segments upsloping depression at the J point of 1 to 3 mm in leads v1 to v6 associated with tall and symmetrical T waves. In this article, we discuss the case of 50 year male who presented to the ER with acute chest pain and was diagnosed with ACS

Case Presentation

A 50-year male with a known history of systemic hypertension for the past 15 years and Diabetic for 3 years on regular treatment presented to casualty with complaints chest pain – pricking type of pain, radiating to left shoulder associated with profuse sweating of 1 hour duration.

He is an occasional alcohol consumer with family history of CAD in his father, who died at the age of 50 due to acute MI.

Clinically – Nil significant

ECG: Showed upsloping ST segment depression and tall, symmetrical T waves in v2- v6 with reciprocal ST depression in lead 11,111,avf

Echo revealed LAD hypokynesia and severe LV dysfunction.

Prompt identification of De Winters sign on the ECG enabled us  to initiate appropriate management for the patient.

Coronary Angiogram was performed which revealed single vessel disease involving LAD. In order to restore blood flow to the myocardium and to prevent further ischemic damage, PTCA to LAD was done. His post procedural period was uneventful. He was treated with antiplatelets, anticoagulant and antilipids, and discharged in a stable condition.


Fig. 1.

ECG showing upsloping ST segment depression and tall, symmetrical T wave in v2 to v6, ST segment depression in 11,111,avf


Fig. 2.



Fig. 3.

Coronary angiogram report.


De Winters sign has been primarily associated with a critical pathology known as acute proximal occlusion of the left anterior descending artery (LAD). This specific coronary artery supplies a significant portion of the anterior wall of the heart, and its occlusion or severe stenosis can lead to myocardial infarction (MI) or ischemia.

Unlike the classic ST-segment elevation observed in a typical STEMI, De Winters sign denotes an occlusion in progress and is classified as an ST-segment elevation myocardial infarction

(STEMI) equivalent


Recognizing De Winters sign on an ECG can be a challenge, as it closely mimics early repolarization, which is often benign and considered a normal variant. However, there are some key differences that should be carefully analyzed.

Early Repolarization ECG De winters sign ECG 
ST segment elevation is more concave ST segment elevation is convex, preceded by down sloping ST segment
STEMI4T wave is asymmetrical STEMI5T wave is tall and symmetrical

Other clues supporting the diagnosis of De Winters sign include the presence of chest pain, reciprocal ST-segment depressions, and new-onset or dynamic changes in the ECG.

Once De winters sign is identified, Coronary angiography (CAG) should be performed urgently to determine the extent and location of the occlusion. In most cases, percutaneous coronary intervention (PCI) is the preferred treatment to restore blood flow and prevent further myocardial damage.


The case discussed highlights the importance of recognizing and understanding the significance of De Winters sign on an ECG in patients presenting with chest pain. Through prompt diagnosis via ECG interpretation and subsequent CAG, this patient was able to receive timely treatment with PTCA to the LAD artery.

This case serves as reminder for healthcare professionals to remain vigilant for atypical ECG patterns and to consider unusual presentations of ACS, ultimately ensuring optimal patient outcomes.


Dr. S. Aravindakumar

Chief Consultant Interventional Cardiologist


Dr. R. Haridha Devi

Duty Medical Officer