Comprehensive analysis of clinical features, electrocardiogram, and imaging in de Winter syndrome

Abstract

Objective:

This study summarizes the clinical characteristics, disease progression, risk factors, electrocardiogram (ECG), and imaging features, and early intervention strategies for patients with de Winter syndrome. It aims to improve understanding and early recognition of this syndrome among clinicians, especially in emergency departments, to ultimately reduce patient mortality.

Methods:

The study cohort comprised 105 patients. Thirteen hospitalized cases were diagnosed with de Winter syndrome at Hainan General Hospital from January 2018 to February 2021, while 92 related cases of de Winter syndrome were identified via PubMed and Web of Science search from January 2000 to June 2025. For all patients, we collected data on age, gender, underlying diseases, family history, primary symptoms, troponin levels, ECG findings, echocardiography results, coronary angiography findings, reperfusion strategies, and in-hospital cardiovascular events for summary and analysis.

Results:

The cohort of 105 patients had a median age of 53.7 ± 13.9 years and most were male (98, 93.3%). Smoking (51,48.5%) and hypertension (32,30.5%) were the primary risk factors, while chest pain (103,98.0%) was the predominant presenting symptom. Of the 68 patients (64.8%) with complete HEART score data, 35 (51.5%) scored 4–6 and 33 (48.5%) scored 7–10. On standard 12-lead ECG, the de Winter pattern appeared most frequently in leads V4 (96, 91.4%) and V3 (95, 90.5%). Dynamic ECG evolution was observed in several patients: 24 cases (22.9%) progressed from the de Winter pattern to ST-segment elevation myocardial infarction (STEMI), while 11 cases (10.5%) evolved from STEMI to the de Winter pattern. Four cases (3.8%) showed evolution from the de Winter pattern to Wellens syndrome, and eight cases (7.6%) displayed concurrent de Winter pattern and STEMI. One case evolved from the de Winter pattern to STEMI and then to a normal ECG; another progressed to non-ST-segment elevation myocardial infarction (NSTEMI); one presented with the de Winter pattern and preexcitation syndrome; and one exhibited the de Winter pattern with complete left bundle branch block. Of the 62 patients (59.0%) with available left ventricular wall motion assessment, 53 (85.5%) showed abnormal motion. Left ventricular ejection fraction (LVEF) was reported for 57 patients (54.3%), of whom 37 (64.9%) had an LVEF <50%. Coronary angiography was performed in 104 patients (99.0%), revealing lesions most commonly in the left anterior descending (LAD) (88,84.6%) artery, followed by the right coronary artery (RCA) (24,23.1%) and the left circumflex (LCX) (23,22.1%) artery; single-vessel disease was predominant (67,64.4%). Complications during hospitalization occurred in 86 patients (81.9%). Of these, 28 patients (32.6%) experienced major complications, the most frequent of which was acute heart failure (17, 19.8%).

Conclusion:

In middle-aged male patients with chest pain as the primary symptom and risk factors such as smoking and hypertension, the ECG warrants scrutiny, particularly for the characteristic changes and evolution of the de Winter pattern in leads V3 and V4. The presence of these characteristic de Winter changes strongly suggests a single-vessel occlusion, most often of the LAD artery. Therefore, improving the recognition of de Winter syndrome and streamlining the emergency percutaneous coronary intervention (PCI) pathway are clinically important for enhancing reperfusion efficiency and patient outcomes.

Introduction

The de Winter syndrome is a rare and distinctive electrocardiogram (ECG) pattern associated with acute, life-threatening coronary occlusion. It represents an equivalent of ST-segment elevation myocardial infarction (STEMI) despite the absence of ST-segment elevation. The typical ECG shows 0.1–0.3 mV upsloping ST-segment depression at the J-point in precordial leads V1-V6, tall symmetrical T waves, and QRS complexes that are usually not wide or only slightly widened; some patients also exhibit poor R-wave progression in the precordial leads. Most present with mild ST-segment elevation in lead aVR. Insufficient recognition of the de Winter ECG pattern in clinical practice can lead to misdiagnosis or delayed diagnosis, postponing urgent reperfusion therapy. Current reports on de Winter syndrome remain fragmented and lack systematic synthesis. This study consolidates the clinical characteristics, electrocardiographic morphology, echocardiographic findings, and coronary angiography results in patients with de Winter syndrome. These findings support the recognition of de Winter syndrome as a STEMI-equivalent. Such recognition aims to improve early diagnosis, guide timely intervention, and ultimately reduce mortality.

2 Materials and methods

Current study compromises tow components:(1)a single-center retrospective case series of patients with de Winter syndrome and (2)a systematic review of published cases. These two datasets were pooled for analysis.

2.1 Single-center case series

We retrospectively reviewed the electronic medical of all consecutive acute coronary syndrome patients presented to Hainan General Hospital between January 2018 to February 2021.Inclusion criteria comprised a diagnosis of de Winter syndrome and the availability of an electrocardiogram examination report.

2.2 Systematic review of published cases

A systematic literature search was conducted in PubMed and Web of Science from January 1,2000 to June 30, 2025 using following terms “de Winter sign”, “de Winter pattern”, “de Winter electrocardiographic pattern”, “de Winter syndrome” and “de Winter”, “ST-segment depression with tall T waves”. The search was limited to human studies and articles published in English. Reference lists of included articles and relevant review papers were manually screened for additional eligible studies.

2.3 Inclusion and exclusion criteria

Studies were included if they meet those criteria:(1)reported on or more cases with ECG findings meeting the de Winter pattern definition as mentioned above;(2)provided individual-level clinical data;(3)were published as full-text original articles, case reports, case series, or brief reports.

Exclusion criteria were:(1)duplicated publicaitons;(2)articles without individual patient data;(3)editorials, comments, or letters without original data;(4)animal or experimental studies.

2.4 Study selection and data extraction

Two reviewers independently screened titles and abstracts, followed by full-text assessment against eligible criteria. Disagreements were resolved through discussion or arbitration by a third reviewer.

2.5 Data extraction and standardization

Demographic characteristics, cardiovascular risk factors(including hypertension, diabetes mellitus, dyslipidemia, smoking, family history of heart disease),clinical presentation, ECG parameters, laboratory findings, coronary angiography results(including culprit vessel, TIMI flow),treatment strategies(percutaneous coronary intervention or thrombosis or conservative),in-pospital adverse events (including malignant arrhythmia, cardiac shock, death) were extracted from extracted from medical records and literature by two independent reviewers (MW, BC) extracted data using a predefined structured form. Disagreements were resolved by consensus or by a third reviewer.

2.6 Quanlity assessment

The Joanna Briggs Institute(JBI) Critical Appraisal Checklist for Case Series was used to access quality of the data of this case series.

2.7 Quality assessment of included studies

Case reports and case series included were assessed by JBI Critical Appraisal Checklist for Case Reports and Case Series respectively. Studies scoring ≥70% of applicable items were considered high quality.

2.8 Integration and analysis

Data from single-center case series and extracted published cases were integrated into a single dataset. Verification was conducted to exclude duplicated cases. Descriptive analysis were performed on the pooled dataset.

Missing data were not imputed. Variables with more than 20% missing value across the pooled dataset were excluded from comparative analysis. Variables with less or equal to 20% values complete-case analysis was performed. Furthermore, the key variables, including clinical characteristics, electrocardiographic findings, and outcomes, are presented separately for the institutional cohort and the literature-derived cases.

2.8.1 General information

The general information comprises the patient's gender, age, underlying conditions (hypertension, diabetes, hyperlipidemia), smoking history, prior history of heart disease, family history of heart disease, and principal clinical symptoms, including chest pain, sweating, and radiating pain.

2.8.2 Troponin I/T

The first post-admission venous blood troponin result was recorded for each patient to calculate the HEART score and evaluate myocardial injury.

2.8.3 ECG

ECG findings documented for each patient included the presence of the de Winter pattern, its lead localization, dynamic evolution, and coexistence with other ECG.

2.8.4 Echocardiography

Echocardiographic data collected for each patient comprised the presence of regional wall motion abnormalities and the left ventricular ejection fraction (LVEF).

2.8.5 Coronary angiography and reperfusion strategy

The data comprised the culprit vessel, the number of diseased vessels, and whether percutaneous coronary intervention (PCI), percutaneous transluminal coronary angioplasty (PTCA), or thrombolytic therapy was administered

2.8.6 Adverse events

Adverse events recorded for each patient encompassed acute heart failure, malignant arrhythmia, cardiac arrest, multiple organ dysfunction syndrome, ventricular aneurysm, and other complications.

3 Results

80 articles published between 2014 and 2025, detailing 92 cases (Supplementary Material), were identified. These cases, combined with our own, formed a final study cohort of 105 patients. The literature screening process is shown in Figure 1.

Figure 1

3.1 General clinical characteristics

The cohort of 105 patients had a median age of 53.7 ± 13.9 years and was predominantly male (98, 93.3%). Patients aged 41–50 and 51–60 years together constituted half of the total (53, 50.5%). The primary risk factors were smoking (51, 48.6%) and hypertension (32, 30.5%). Most patients (100, 95.2%) presented with a first episode of coronary heart disease, while five (4.7%) had a prior history. Chest pain was the principal symptom (103, 98.1%), frequently accompanied by sweating (36, 34.3%) and often radiating (23, 21.9%).Among the 13 institutional patients, all (100.0%) presented with chest pain; in the 92 literature-derived cases, 90 (97.8%) reported this symptom. The average age and proportion of male patients were also similar between between the institutional cohort and the literature-derived cases. Significant differences between the 13 institutional patients and the 92 literature-derived casewere observed regarding histories of hypertension, diabetes, and hyperlipidemia (Table 1, Figure 2).

Figure 2

3.2 Troponin and HEART score

HEART scores could not be calculated for 37 patients due to missing troponin levels or an unspecified troponin assay reference standard. Scores were therefore determined for the remaining 68 patients (64.8%). Among these, 35 patients (51.5%) had an intermediate-risk score of 4–6 points, while 33 patients (48.5%) had a high-risk score of 7–10 points (Table 2).

3.3 ECG

105 patients' ECGs showed a de Winter ECG pattern (upsloping depression of the ST- segment, tall and symmetrical T wave), which can occur in the inferior wall lead and precordial chest lead (Figure 3). The highest proportion of this feature occurring in the precordial leads is V4 (96, 91.4%), V3 (95, 90.4%), V5 (86, 81.9%), and V2 (74, 70.4%). The de Winter pattern was most frequently observed in lead V4 in both our institutional cohort (13, 100.0%) and literature-derived cases (83, 90.2%) (Table 3). In addition, this study also observed the dynamic evolution of the de Winter ECG pattern, with 24 cases (22.9%) of de Winter ECG pattern evolving into STEMI, 11 cases (10.4%) of STEMI dynamically evolving into de Winter ECG pattern, 4 cases (3.8%) of de Winter ECG pattern dynamically evolving into Wellens syndrome, 8 cases (7.6%) of de Winter ECG pattern combined with STEMI, 1 case each of de Winter ECG pattern with pre excitation syndrome and de Winter ECG pattern with complete left bundle branch block.

Figure 3

3.4 Imaging examination and reperfusion treatment

Cardiac color Doppler ultrasound results were available for some patients, with left ventricular wall motion reported in 62 (59.4%) cases and LVEF in 57 (54.3%). Of these, 53 (85.5%) had abnormal wall motion, and 37 (64.9%) had an LVEF < 50%. Coronary angiography was performed in 104 patients (99.0%), revealing the most common lesion location as the left anterior descending (LAD) (88, 84.6%), followed by the right coronary artery(RCA) (24, 23.1%) and the left circumflex(LCX) (23, 22.1%); the left main (LM) (10, 10.0%) artery and the first diagonal branch (D1) (6, 5.8%) were also involved; lesions were primarily in single vessels (67, 64.4%) (Table 4). Representative color Doppler ultrasound and coronary angiography images from some patients are presented in Figures 4, 5. PCI or PTCA was performed in 100 patients (95.2%), while five patients (4.8%) received pharmacological thrombolysis, which was successful in two cases.

Figure 4

Figure 5

3.5 Occurrence of adverse events

Complications during hospitalization were reported by 86 patients (81.9%). Of these, 28 patients (32.6%) experienced complications, primarily acute heart failure (17, 19.8%), malignant arrhythmia, and multiple organ dysfunction. Four patients (4.6%) died, one patient with a diagnosis of de Winter syndrome and severe aortic stenosis developed a groin hematoma following percutaneous aortic valve replacement during hospitalization. The most common adverse event was acute heart failure, which occurred in both our institutional cohort (3, 27.3%) and in the literature-derived cases (14, 18.9%) (Table 5).

4 Discussion

4.1 Clinical features

From this cohort we see that de Winter pattern is more prevalent in male (93.3%) and aged 41–60 years (50.5%). This is in line with the findings of de Winter et al (1), and likely reflects the progression of coronary atherosclerosis, the influence of androgen levels on vascular endothelial function, and a higher prevalence of risk factors in men (2). Smoking and hypertension were the most prevalent risk factors, whereas diabetes and hyperlipidemia were less common. Furthermore, 95.3% of patients presented as first episode. The abrupt onset, often without obvious provocation during daily activities, underscores the occult and unpredictable nature of this syndrome. The primary symptom is chest pain, sometimes accompanied by sweating or radiating pain. Notably, some episodes occurred at night or during sleep, resembling resting angina pectoris, which implicates circadian sympathetic activity or coronary vasospasm in the pathophysiology, as also suggested by Hirohiko Ando et al. (3). Given this clinical diversity, clinicians should integrate ECG findings with other diagnostic modalities when evaluating chest pain and avoid relying solely on subjective symptoms.

4.2 ECG changes

The de Winter ECG pattern is identified by specific ST-T morphologies and amplitudes. The combination of upsloping ST-segment depression with symmetrically tall T-waves is a classic and highly specific sign of acute coronary thrombosis. Originally considered a static finding, the characteristic manifestations of this pattern are now understood to evolve dynamically. In this study, the pattern converted to STEMI in 24 cases and from STEMI to the de Winter pattern in 11 cases.

Conversion from the de Winter pattern to Wellens syndrome was also reported in 4 cases. After reperfusion therapy, the ST segment returned to baseline in some cases. One case evolved to STEMI and then to a normal ECG after reperfusion therapy, while another case converted to non-ST-segment elevation myocardial infarction (NSTEMI). These indicate that de Winter pattern is transient state and can transition to STEMI, NSTEMI, Wellens pattern or a normal tracing, representing a dynamic ischemic state during coronary occlusion. This evolution, involving interconversion between patterns, may relate to unstable thrombus, spontaneous thrombolysis, or coronary recanalization (4). Consequently, repeated ECG examinations are essential in patients with chest pain to capture these dynamic ST-T changes.

The de Winter ECG pattern can occur in different leads, with a higher prevalence in the anterior leads V4 (91.4%), V3 (90.4%), V5 (81.9%), and V2 (70.4%). Literature reports indicate that these pattern also can be seen in inferior leads, with clinical significance generally attributed to changes in three or more contiguous leads (5). However, Song et al. (6)documented a case where the de Winter pattern was present solely in lead V2, and subsequent coronary angiography confirmed severe stenosis of the left anterior descending artery (LAD). The associated T-wave changes are attributed to severe transmural ischemia from a critical subtotal LAD occlusion, producing a hyperacute T-wave-like morphology distinct from the peaking caused by ventricular repolarization abnormalities like hyperkalemia or bundle branch block. The amplitude, persistence and symmetry of the T-waves in this pattern are characteristic. When combined with clinical symptoms such as persistent chest pain, profuse sweating, and a sense of impending doom, diagnostic accuracy improves significantly. Early recognition of de Winter ECG pattern as a sign of sudden occlusion of coronary artery can facilitate timely reperfusion to restore coronary blood flow. Existing case reports remind that misdiagnosis often occurs in primary healthcare settings or in non-cardiovascular specialties during early presentation. Some patients are even misdiagnosed with acute gastrointestinal disorders or neurogenic chest pain. A rapid identification protocol in emergency departments, incorporating the de Winter pattern into the STEMI-equivalent diagnostic pathway, is therefore recommended. For chest pain patients whose ECG shows upsloping ST-segment depression with tall, symmetrical T-waves, direct emergency coronary angiography should be performed to confirm the occlusion of coronary artery and followed by timely reperfusion therapy. Training for both electrocardiographers and clinicians should explicitly emphasize this syndrome's existence and critical significance to reduce misdiagnosis.

On the other hand, de Winter pattern alikes can be seen in hyperkalemia (7), acute myocarditis (8), or pheochromocytoma (9). This indicates that diagnosing coronary occlusion in de Winter syndrome cannot rely solely on characteristic ECG changes but must integrate patient symptoms, signs, and other auxiliary examinations. As suggested by Sandro et al. (10)_, although the ECG may indicate a de Winter pattern, diagnosing LAD occlusion based solely on this finding remains controversial.

4.3 Imaging and interventional characteristics

4.3.1 Echocardiography

Typical findings in echocardiography in patients with de Winter syndrome including regional wall motion abnormalities (RWMAs) of the left ventricle, commonly affecting the anterior wall, anteroseptal wall, and apex. These abnormalities correspond to acute ischemia or injury within the myocardial territory supplied by the LAD. Among the study patients with reported echocardiographic results, 53 (85.5%) exhibited RWMAs of varying severity, and 37 (64.8%) presented with a LVEF below 50%. Follow-up echocardiography several days after PCI in some patients showed marked improvement in cardiac function, indicating that the myocardium had not yet experience complete necrosis and affected myocardium remained reversible. This observation aligns with the typical temporal window for de Winter syndrome, which occurs during the early phase of acute coronary occlusion. In a subset of patients with de Winter syndrome, no significant cardiac morphological or structural abnormalities was detected in echocardiography while coronary occlusion was confirmed by coronary angiography. RWMAs seen in de Winter pattern patints could be supporting findings of coronary occlusion.A normal echocardiography could not exclude coronary artery occlusion in de Winter pattern patients.

4.3.2 Culprit artery

Coronary angiography is the gold standard to identify culprit coronary artery of de Winter syndrome. Previous studies have suggested that the culprit vessel is typically LAD. However, with the continuous reporting of clinical cases, it has also been found that the culprit vessel may be other coronary arteries, including the left main (LM) artery (11), the D1 (12), the LCX (13), and the RCA (14). Among all included cases, the LAD was the most frequently involved vessel, accounting for 88 cases (84.6%), followed by the RCA (24, 23.1%) and the LCX (23, 22.1%). Single-vessel disease was predominant (67, 64.4%), although multi-vessel disease was also observed, which is consistent with similar research findings (15). Notably, a significant thrombus burden was observed at the lesion site in some patients, suggesting that the pathological basis may involve atherosclerotic plaque rupture and local acute thrombosis. In some angiographic examinations, delayed distal perfusion or reduced TIMI flow was observed, further supporting that LAD occlusion leads to extensive anterior wall myocardial ischemia.

4.3.3 Reperfusion therapy strategy

The culprit lesions corresponding to de Winter syndrome exhibit certain patterns and should be strategically regarded as a STEMI-equivalent category. PCI is considered the optimal reperfusion strategy, or alternatively, early intravenous thrombolytic therapy should be administered. Among the 105 patients included in this study, 100 underwent PCI or PTCA, while 5 received intravenous thrombolysis. The reasons for selecting thrombolysis were as follows: one patient refused coronary angiography, and four patients were treated at hospitals lacking interventional capabilities or with catheterization laboratories unavailable. Ultimately, successful reperfusion was achieved in 2 patients following thrombolysis (16). Guidelines for the diagnosis and treatment of STEMI ecommend intravenous thrombolytic therapy for STEMI (17). However, whether de Winter syndrome, as a STEMI-equivalent, is an indication for thrombolysis remains controversial. In our case series, the de Winter ECG pattern and STEMI were observed to be mutually convertible. The de Winter ECG pattern may represent a hyperacute phase of STEMI, suggesting that thrombolytic therapy could be applicable for de Winter syndrome from this perspective. In practice, however, not all de Winter ECG patterns progress to STEMI. In some patients, the ST segment spontaneously returns to baseline following relief of chest pain without manifesting ST-segment elevation. When emergency PCI is unavailable in de Winter patients, thrombolysis may be a potential option (16, 18) but need more evidence in this scenario. Considering that patients with de Winter syndrome often present with severe ECG ischemic signs without ST-segment elevation, it is recommended to include the de Winter ECG pattern in the risk stratification of patients presenting with acute coronary syndrome (ACS). An automated recognition system should be implemented in the pre-screening process of chest pain centers to prevent delays in the interventional treatment window due to failure to meet traditional ST-elevation criteria. On the other hand, as the emergency department is the initial point of contact for most patients with chest pain, emergency physicians may consider using the HEART score for risk stratification when the etiology of chest pain is unclear. In this study, the HEART score was calculated for 68 patients (67.8%). The results indicated that 35 patients (51.5%) scored 4–6 points (intermediate risk), and 33 patients (48.5%) scored 7–10 points (high risk). This demonstrates that the HEART score is applicable for preoperative risk stratification in de Winter syndrome, facilitating early and aggressive intervention for high-risk patients.

4.3.4 Clinical outcomes

In de Winter syndrome, the condition often progresses rapidly without prompt recognition, leading to widely variable clinical outcomes. Coronary angiography typically shows subtotal or total occlusion of the proximal or mid-segment LAD artery, with only a minority of patients having concomitant multivessel disease. This anatomical pattern carries a high risk of myocardial injury. A delay in diagnosis for some patients postponed reperfusion therapy, causing severe complications such as cardiogenic shock, acute left heart failure, and cardiac arrest. Data on in-hospital complications were available for 86 patients (81.9%). Among these, 28 patients (32.6%) experienced complications during their hospitalization. The most frequent complications were acute heart failure (17, 19.8%) and malignant arrhythmias (5, 5.8%). Two deaths (2.3%) occurred. Two patients (2.3%) developed a ventricular aneurysm, and one patient with de Winter syndrome and severe aortic stenosis developed a groin hematoma after percutaneous aortic valve replacement. Most patients recovered well following emergency PCI, underscoring that early recognition and timely intervention are critical for improving prognosis.

5 Conclusion

This study combined institutional cases (n = 13) with those derived from the literature (n = 92), which introduced a degree of heterogeneity. The high proportion of missing data for several key variables, such as troponin levels, HEART scores, and echocardiographic findings, may also limit the generalizability of the results. Due to the risk of bias and insufficient statistical power, formal hypothesis testing was not performed. However, the extreme rarity of de Winter syndrome precludes meaningful analysis from a single-center cohort; aggregating published cases enables a more comprehensive description of its clinical and electrocardiographic spectrum. This pooled analysis is therefore exploratory and hypothesis-generating, not confirmatory. De Winter syndrome is predominantly observed in middle-aged males, with smoking and hypertension being the most common risk factors. Chest pain serves as its primary clinical symptom. The de Winter ECG pattern is not confined to the precordial leads; it may also manifest in the inferior leads or occur simultaneously in both inferior and precordial leads, most frequently in leads V3 and V4. This specific ECG pattern exhibits transient or persistent dynamic evolution. The de Winter pattern is mostly associated with single-vessel coronary artery disease and is useful for diagnosing an acute proximal LAD artery obstruction. The presence of a de Winter syndrome pattern may be associated with high rates of complications and mortality without aggressive treatment. This rare electrocardiographic manifestation of acute left anterior descending artery occlusion has garnered increasing attention for its diagnostic and clinical significance. Greater sensitivity to such patterns enables the immediate prediction of the culprit vessel and an assessment of myocardial ischemia extent. Its characteristic electrocardiographic features indicate that de Winter syndrome should occupy a definitive position within the diagnostic and therapeutic framework for acute chest pain.

The findings support recognizing de Winter syndrome as a STEMI-equivalent, Strengthening recognition awareness, optimizing emergency PCI procedures, and integrating standardized imaging evaluation with precise treatment strategies contribute to improving reperfusion efficiency, enhancing patient prognosis, and reducing rates of misdiagnosis and treatment delay.Due to the descriptive nature of the literature review design and data aggregation in this study, we did not perform formal statistical tests for heterogeneity, such as the I² or Q test, or conduct meta-regression. This represents a limitation of the present work.Though prospective validation is needed before definitive prognostic or implementation claims are possible. Future prospective registry studies should test the hypotheses generated here to identify predictors of adverse outcomes.

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