Introduction: The Winter ECG pattern is an anterior STEMI equivalent that presents without obvious ST segment elevation. Key diagnostic features include ST depression and peaked T waves in the precordial leads. The de Winter pattern is seen in ~2% of acute LAD occlusions and is under-recognised by clinicians. Unfamiliarity with this high-risk ECG pattern may lead to under-treatment, with attendant negative effects on morbidity and mortality.
Case presentation: We present the case of a 41-year-old patient with chest pain that occurred after a sustained physical onset of about 6 hours before admission. On admission, the patient was hemodynamically stable, with a blood pressure of 120/80 mmHg, in sinus rhythm 67 bpm, ST horizontal depression 1-3mm V₂-V₆, symmetrical and peaked T waves in V₂-V, 1mm ST elevation in aVR, with normal clinical examination. Blood sample results showed inflammatory syndrome, leukocytosis with neutrophilia, hypercholesterolemia, hypertriglyceridemia, hyperglycemia, microalbuminuria, CK_MB at the upper limit of normal. Echocardiography, the left ventricul has normal dimensions with severely reduced overall systolic function (30%), by apex akinesia, 1/3 apical interventricular septum, anterior wall, lateral wall, no sign of pulmonary hypertension, moderate mitral regurgitation.
The changes observed on the EKG, corroborated with anamnestic and echocardiographic data, we chose to do a coronarographic evaluation, which objected: left main with no lessions, fistula between the proximal segment of anterior descending coronary artery and the pulmonary artery, acute thrombotic occlusion in the proximal segment of the anterior descending artery, right coronary artery and circumflex artery with no lesions. Percutaneous transluminal angioplasty with DES stent was performed at anterior descending artery first segment, distal to the stent a 75% stenosis was observed. The second DES stent was superimposed over the distal margin, with a very good final result, TIMI 3 flux.
Conclusions: The case presented is a rare case of STEMI equivalence in which an arterio-arterial malformation (fistula between the anterior descending artery and the pulmonary artery) has been found, in the context of addressing with angina symptoms, in the absence of enzymatic dynamics. Consequently, we emphasize the importance of electrocardiogram interpretation by clinicians for an early diagnosis and the choice of an appropriate therapeutic approach.