The “criminal” artery of de Winter may be the left circumflex artery: A CARE-compliant case report

RATIONALE: De Winter et al first described a new ST-segment elevation myocardial infarction (STEMI)-equivalent pattern associated with acute occlusion of the left anterior descending coronary artery (LAD). Studies show that this pattern has a positive predictive value of 95.2% to 100%. However, some cases of non-STEMI, caused by acute right coronary artery or LAD diagonal branch occlusion, have been reported, which exhibit electrocardiogram (ECG) changes similar to the de Winter pattern. Few cases of de Winter ECG pattern caused by left circumflex artery (LCX) stenosis have been reported. PATIENT CONCERNS: A 57-year-old man was admitted to the emergency department 12 hours after suffering from oppressive chest pain and diaphoresis. The patient had a history of diabetes and smoking. An initial ECG showed atrial fibrillation, upsloping ST-segment depression at the J point, followed by peaked, positive T waves in leads V2 to V6 and slight ST-segment elevation in lead aVR, with poor R-wave progression. Coronary angiography showed tubular stenosis (up to 95%) of the proximal portion of the LCX. DIAGNOSIS: LCX stenosis led to a diagnosis of non-STEMI. INTERVENTIONS: Left coronary artery stenosis was successfully treated with angioplasty and insertion of a drug-eluting stent. OUTCOMES: The patient's chest pain resolved completely after stent implantation. No myocardial infarction occurred during the 6-month follow-up period. LESSONS: De Winter ECG pattern cannot be presumed to be associated with LAD stenosis and 18-lead ECG is required to support the identification of the “criminal” artery and to rule out posterior myocardial infarction.