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.

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.

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.

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.

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.

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

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.

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.

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).

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).

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.

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.

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).

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.

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.