ECG of the month: A “de Winter”-like ECG pattern in a patient presenting with progressive lethargy

Hyperkalemia mimicking de Winter T waves: A case report

“…In contrast, our case presented with chest pain and elevated cTnI, which suggest an acute coronary syndrome. In addition, although the P‐R interval and P wave had dynamic change after emergent hemodialysis, they were within the normal range and lacked remarkable electrocardiographic changes of hyperkalemia as in Walker et al's 3 report.…”

“…In fact, hyperkalemia‐induced pseudo‐myocardial infarction has been widely reported 3,6–15 ; however, most cases presented with typical ST‐elevation on ECG as STEMI, with only Walker et al 3 recently reported a similar case with hyperkalemia presented with “de Winter‐like” ECG. However, in Walker et al's 3 report, this case mainly complained of lethargy rather than chest pain symptoms. Moreover, this case had other characteristics of severe hyperkalemia, such as bradycardia, widened QRS duration, and sinoventricular conduction.…”

“…Indeed, highpitched T wave in hyperkalemia usually resembles the hyperacute phase of STEMI; however, the ST-segment in hyperkalemia is usually not depressed, and "de Winterlike" pattern was scarce. In fact, hyperkalemia-induced pseudo-myocardial infarction has been widely reported 3,[6][7][8][9][10][11][12][13][14][15] ; however, most cases presented with typical STelevation on ECG as STEMI, with only Walker et al 3 recently reported a similar case with hyperkalemia presented with "de Winter-like" ECG. However, in Walker et al's 3 report, this case mainly complained of lethargy rather than chest pain symptoms.…”

“…Although this electrocardiographic pattern was not classic ST‐elevation myocardial infarction (STEMI), it usually indicates the left anterior descending artery (LAD) occlusion, and now it is recognized as a special equivalent of STEMI needing urgent reperfusion therapy 2 . However, “de Winter‐like ECG” pattern is not specific for STEMI, and hyperkalemia‐caused electrocardiographic change is one of the most important differential diagnoses 3 . Here, we reported a case with chronic kidney disease (CKD) complicating hyperkalemia presented with “de Winter” pattern on electrocardiogram (ECG).…”

“…2 However, "de Winter-like ECG" pattern is not specific for STEMI, and hyperkalemia-caused electrocardiographic change is one of the most important differential diagnoses. 3 Here, we reported a case with chronic kidney disease (CKD) complicating hyperkalemia presented with "de Winter" pattern on electrocardiogram (ECG).…”