Thrombolysis in the de winter electrocardiography pattern: A therapeutic dilemma

The de Winter's pattern is an electrocardiography (ECG) finding characterized by ST depression and tall prominent T-waves in precordial leads with ST elevation in lead aVR. It signifies the occlusion of proximal left anterior descending artery (LAD). Although it is considered a ST-elevation myocardial infarction (STEMI) equivalent, current guidelines recommend against the use of thrombolytic therapy in the absence of STEMI. As the question whether to use thrombolysis in such situations remains unanswered and controversial, we preferred to provide thrombolytic therapy with tenecteplase to our patient admitted with acute retrosternal chest pain with de Winter's ECG pattern so as to prevent myocardial damage and improve the patient outcome as the percutaneous coronary intervention facility was not immediately available. The thrombolysis was successful and the proximal LAD occlusion was confirmed later on coronary angiography which was treated with stent implantation. This case report tends to highlight the therapeutic dilemma while managing patients with de Winter's ECG pattern.