Subtle de Winter in a 40 Years Old Male with No Chest Pain

BACKGROUND: It is well known that the Electrocardiogram (ECG) is the first and most important test to diagnose patients with acute coronary syndrome (ACS). ST elevations on ECG in a patient presenting with chest pain is defined as ST elevation myocardial infarction (STEMI) and is confirmed by cardiac catheterization. Various STEMI equivalents have been reported in the literature. Most STEMI equivalents are often missed or not recognized by physicians. So, giving attention to these presentations are very important for physicians and cardiologist. The de Winter ECG pattern is one of the rare STEMI equivalents presentations which deserves emergent reperfusion therapy. CASE REPORT: This case report describes a very subtle ECG pattern which found to have critical occlusion of the proximal left anterior descending (LAD) artery in a previously healthy 40-year-old patient who presented to the Emergency Department (ED) with no chest pain. The patient did not have any risk factors for ACS and was not taking any medication. The initial ECG showed mild ST depression, which was changed to biphasic T wave later on. Recognizing this specific ECG pattern is important to direct patients toward appropriate management early and prevent delay in diagnoses